Ethical Obligations and Duty to Advocate for Patients in Prior Authorization for Surgery

Prior authorization delays or denial can harm patients both clinically and psychologically. It was important for the otolaryngologist to explain the situation in full transparency so as to support the family’s trust in them, and to also support the parental autonomy and Cindy’s hopes. This scenario brings into view the multi-ethical principlism of beneficence, non-maleficence, and autonomy, but especially justice and equity for Cindy, who deserves equitable access to reconstructive surgery regardless of payer or patient resources.

As physicians first and otolaryngologists second, we are bound by professional duties, guidelines, and expectations from society to consider and represent the patient’s best interests in all aspects of their care. Dealing with insurance payers is one of the least valued of all of our duties, but duty it is. We are ethically obligated to advocate for care that restores function, mitigates disfigurement, and improves psychosocial development and well-being, especially in a child. There is no denying that any aged child or adolescent can face potential appearance-targeted bullying, harassment, or belittlement, and there is plenty of that occurring these days at schools and on social media. Even a four-year-old child such as Cindy can face very hurtful behavior and comments from others that can have a lasting impact on her self-worth and self-confidence.

Other issues of professional duty and ethics involve social justice and full access to care for a patient’s injuries. Denial of medically necessary reconstructive surgery for a child on Medicaid/CHIP raises serious concerns of distributive justice and fairness. In Cindy’s circumstance, the parents would be unable to afford private insurance or even fee-for-service charges to revise the low functional impact scars, which would place a clear and deep burden on their limited financial resources. Children from disadvantaged backgrounds should not face barriers to function- and appearance-restoring surgery that might be readily approved for privately insured patients; however, in reality, even private insurers often deny such procedures that are likely to be costly to them.

Patients are right to expect us to discharge our duties to care for them, even if it involves additional time and effort, and generally appreciate our advocacy on their behalf. The otolaryngologist is the leader of their care team for the longitudinal pathway from injury repair to the ultimate best possible outcome. That trust may require our “going the extra mile” to coordinate their care successfully and to repeatedly earn their trust. Surgeons do not often think of themselves as “patient navigators,” but this term seems to fit this scenario quite well. Poor documentation and preparation of prior authorization requests and appeals can not only be harmful to the patient, but also to the patient–physician relationship, as trust can be eroded and dissatisfaction ensues. Timely and successful prior authorization efforts by otolaryngologists on behalf of their patients are not merely a clerical task; it is also an ethical duty.