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Episode 2 of “The Prior Authorization Games”

Op-Med is a collection of original articles contributed by Doximity members.

Greetings Readers. I thought I would try something new and start somewhat of a series. If you didn’t see my original post on prior authorizations, this link will take you right to it.

Last week I found myself on the phone, yet again arguing on behalf of a patient, to overturn the denial of the insurance company to pre-authorize a PET/CT scan.

The conversation was as usual, frustrating and, a waste of 15 minutes of my clinic time where I had to keep another patient waiting in the exam room. (Because the insurance physician is only available during clinic hours, I cannot wait until after 5 PM when I am finished with my patients, but must sacrifice my schedule and keep other patients waiting in order to complete the phone call). While in the end I obtained the approval for my patient, I was frustrated with the usual ridiculousness of the “peer-to-peer” discussion.

Here, is a summary of the conversation:

Insurance physician (IP): “So, I see here this request is for a PET/CT scan?”

Me: “Yes. Let me tell you about the patient. But first, I want you to know, I’ve been kept waiting on hold for 13 minutes, waiting to speak to you.”

IP: “Uh, Ok.”

Me: “Mrs. X. has a metastatic cancer of unknown primary. As part of our work-up to find the origin of the cancer, I need for her to have a PET/CT scan.”

IP: “So, what is the primary site of her cancer?”

Me: (deep breath) “That’s what I’m telling you, we don’t know. It is a cancer of unknown primary. That’s why I am ordering the PET/CT scan — to try to help us find the site of the primary, in order to best recommend treatment options.”

IP: “Why can’t she have a CT scan?”

Me: “She did have a CT scan. It showed some possible thickening in the lower esophagus, and no other site of possible primary. But she had a negative endoscopy. The PET/CT scan will help us see if there is metabolic activity in the esophagus, or anywhere else.”

IP: “Oh, she had a CT scan already?”

Me: (another deep breath, count to 10) “Yes.”

IP: silence

Me: “I assure you, as a board certified oncologist, this is well within the standards of care of oncology.”

IP: (after a few more seconds of silence). “Ok, I’ll give you an approval number…”

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