I could have sent [the patient] to the ER to get the test right away, but we shouldn’t have to do that. We are board-certified specialists trying to deliver quality care to patients. —Steven Gold, MD
Explore This IssueAugust 2019
When peer-to-peer review is required, the payer’s medical representative is typically not an otolaryngologist. Instead, these representatives tend to be pediatricians, psychiatrists, or retired physicians from other fields. “They are not familiar with the literature and data regarding the clinical issue under consideration,” said Dr. Setzen.
Prior Authorization and Otolaryngology
When a patient comes in for treatment for chronic rhinosinusitis (CRS), the prior authorization delay ends up actually costing money, said Richard R. Orlandi, MD, professor of otolaryngology–head and neck surgery and chief medical officer of ambulatory health at the University of Utah Health in Salt Lake City and past president of the American Rhinologic Society. “The indirect costs outweigh the direct costs. The prior authorization process can increase the indirect economic costs and thus [increase] the overall economic burden of the disease to the individual, her employer, and society overall,” he said.
When a patient needs a CT scan to confirm a diagnosis, prior authorization typically delays the scan, but nearly all cases get approved; however, when a patient needs to wait three days for the scan instead of getting it the same day, “the patient has to take more time off work to have the scan, then take more time away from work to have a discussion with me about the results and next treatment options, even if it’s over the phone,” said Dr. Orlandi.
Ironically, “in an effort to decrease costs for an employer-purchased insurance, the insurers actually make patients take more time away from work, thereby negatively impacting the employees’ economic contribution to the employer,” said Dr. Orlandi.
CT scans of the neck or sinuses, new technology such as a hypoglossal nerve sinus implant to treat sleep apnea, and balloon dilation in the Eustachian tube and sinus have very specific criteria that often require peer-to-peer review for prior authorization. Certain medications, such as the newer monocolonal antibody biologics used for asthma and CRS with polyps, also trigger prior authorization due to their expense, said Dr. Orlandi.
“These typically go through a robust prior authorization process, and it’s not uncommon for the request to be rejected,” he added. “Sadly, these patients may have exhausted all other options, and [this has a] significant impact on quality of life. The need to control this expensive treatment and the need to improve these patients’ health needs to be better balanced.”