Has your doctor ever recommended a service or treatment that required pre-approval by your insurer? What’s the reason behind this extra step? Find out in this episode of Blue Promise.
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Blue Promise is a podcast and online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.
DAN: Has your doctor ever recommended a service or treatment that required pre-approval by your insurer? What's the reason behind this? Find out in this episode of Blue Promise. Thanks for tuning into Blue Promise, where we’re committed to addressing complicated health issues with candid conversations from subject matter experts. Hello, I'm Dr. Dan McCoy. I'm the President of BlueCross BlueShield of Texas. I'm joined in the studio today by Dr. Leslie Weisberg. She's our chief medical officer in southwest Texas. Leslie, welcome to Blue Promise.
LESLIE: Thank you, it’s good to be here.
DAN: So, why do some health treatments require a pre-approval by an insurance company?
LESLIE: So, typically these health treatments require prior authorization, which is a request for a medical or surgical procedure or a drug prescription that needs to be reviewed against nationally recognized evidence-based guidelines. And we do this to ensure that our members get the appropriate care, in the appropriate place, at the appropriate time.
DAN: So, what determines if a procedure is going to need a pre-approval?
LESLIE: So, typically we focus on procedures that may be high cost, may have a high risk to our members, as well as procedures or drugs that may have off-label use or indications that don't follow the medical base guidelines.
DAN: Give me an example of a procedure that would be like in each of those categories, like high cost. What's an example of a high cost procedure that typically needs a preapproval?
LESLIE: So, typically an example would be a cervical fusion. That's a high cost procedure that we have medical policy guidelines about that would require a prior authorization. And the prior authorization looks at things such as surgeries, has the patient failed conservative therapy, have they tried alternate measures? To ensure that we’re giving our patients or helping our patients, I should say, get the most appropriate and effective care.
DAN: Okay, so you’re going to have to help me out here. So, what's a cervical fusion?
LESLIE: So, a cervical fusion is a procedure on the spine that is performed to help relieve back pain, neck pain, as well as sometimes things such as numbness or tingling in the hands.
DAN: Okay, so does that also play a role in patient safety too though?
LESLIE: Yes, it does. Because by doing procedures such as that, that the physician has not attempted conservative measures for the member. These do have potential complications, although they would be unintended. We just want to make sure that they're getting the procedure and they follow through to meet the criteria.
DAN: OK. So, what do the medical directors and insurers usually look to, to provide the guidance, if you will, in making a determination if something should be pre-approved or not?
LESLIE: So, the medical directors rely on our four hundred and seventy-five plus medical policies and these policies are reviewed on a yearly basis, sometimes more frequently if there been significant studies done that showed that we need to update the policy more frequently. And these policies are based on evidence-based medicine. So, they look at the medical literature available and base it on large randomized controlled studies. And so, in this way we know that in a large cohort or population of individuals, this procedure, test, or drug has shown improvement in a large number of patients. So that's what the medical directors use.
DAN: But why can't you just rely on your doctor to make that decision? And why do you need to look at evidence-based medicine?
LESLIE: As a health care practitioner in 2019, there's a lot to keep up with. And so, sometimes a doctor may not always be aware of a recent change or update in the medical literature. Or sometimes he or she may think that a drug that is used for one indication or say may also be used for an off-label use when again, it doesn't have the criteria or data to support it.
DAN: So, it sounds like to me that you have a team of people that are actually looking at this information. So, are these policies updated on a regular basis or how often do you look at the literature to make a determination if maybe a pre-authorization needed to be revised?
LESLIE: So, the prior authorization list is updated on a yearly basis. So right now, the 2020 prior authorization list has been reviewed and confirmed. Beginning of 2020, we start preparation for 2021 prior authorization list. And then with regards to the policies, the medical policies, those reviewed on a yearly basis.
DAN: Okay. So, it sounds like when we start talking about prior authorizations and you know your doctor's decision being questioned, that could seem at least like it's a cold kind of business decision that has to be made about often a very emotional time for a patient, who's struggling with a health care issue. Tell me a little bit about the process that the member can experience when going through your prior authorization, why it's necessary, and maybe some things that we try to do to make it better.
LESLIE: So, the prior authorizations are necessary to ensure again that members get the appropriate care or the appropriate drug. It's important to have prior authorizations so that members don't have unintended complications from drugs or procedures that are not medically necessary. So, that is something that we feel is a very important reason why we continue with the prior authorizations. With regard to other reasons to continue with the prior authorization process, is that it also helps to prevent fraud, waste, and abuse. And this can also result in increased premiums for our members, if we’re approving care that is not medically necessary or that is considered fraud or waste.
DAN: So, in that example, maybe the patient or the member may not even really realize that this procedure is sort of at risk for fraud, waste, and abuse. Give me an example of that? So, what's an example where prior authorization could maybe prevent a fraud from occurring?
LESLIE: So, an example would be the use of injectable amniotic membrane fluid for different orthopedic complaints such as fibromyalgia or shoulder or back pain.
DAN: So, I guess there's no evidence-based medicine for those kinds of treatments.
LESLIE: There is not, and, in all indications, it would be considered experimental, investigational and unapproved.
DAN: So, maybe the patient's going through a painful procedure for no real evidence-based benefit. So that's an example where prior authorization maybe steps in and prevents something that's both, not necessarily helpful for the patient, but also maybe have some fraud, waste, and abuse to it as well. So, are there any exceptions to this process?
LESLIE: So, exemptions, certain types of items don't require prior authorization. The lists are posted on our BlueCross BlueShield Texas website. So, we encourage providers and members to always check that. Emergent procedures, so if you have to go to the hospital for an appendectomy or other type of emergency procedure, you do not have to be prior authorized. If the inpatient stay for a longer period of time than that, those days would need to be prior authorized. But typically, emergent conditions do not require prior authorizations.
DAN: So, the other thing I think too is that people tend to focus on procedures. And we certainly have, in Blue Promise today, we've talked about all these different procedures that people can get. But I would suspect, knowing where the cost trends are today. Which I remember, when I started at Blue Cross about four or five years ago, the amount that we spent on pharmaceuticals was like around 10 percent of a premium dollar. Today, it's over thirty one percent of a premium is spent on drugs. I suspect that drugs play an increasing role in prior authorization too.
LESLIE: Definitely. Our specialty review pharmacy has continued to increase the number of drugs that are on the prior authorization list for review. An example would be something like intravenous gamma globulin. That particular drug does have a lot of evidence-based indications such as for individuals that are immunodeficient. However, it also has a number of, the reason why it requires prior authorization is because it's also used off- label for a number of indications which are not always supported by the medical literature. It's a very expensive therapy and usually given multiple times over the course of an individual’s lifetime. That's why it’s important for us to prior authorize or review drugs like that.
DAN: So, this growth and the cost of drugs is really and also the number of drugs to, which are very complicated, I suspect too. So, they kind of fit both your criteria. They are both expensive and these new drugs that are coming out have very specific indications, they’re very complicated to use, things of that kind of nature. I recently became aware of a member issue and it kind of came to me that this person was going to have a C.T. scan tomorrow. And they were really concerned because there was a prior authorization pending. And I think I even reached out to you about that case and said, “Hey, so, what's going on?” And what we found was is that the physician hadn't even submitted the prior authorization. So, what are some things that members can do to help their doctor navigate this process too. Because it is a little bit of an issue that the physician has to be involved in. What could we do to help them?
LESLIE: So, I think that as members, what they can do to help the physicians is to, before they leave the office, know what is going to be done and then make sure you check with the office before going through the procedure to make sure that that prior authorization has been submitted and approved. If it’s something that needs to be done emergently, they can always submit it as an emergent prior authorization, so the turnaround time for approval, or I should say review, will be much quicker. I think that members would want to work first with the physician ordering the test to make sure that that was submitted. And then the member or the physician can contact customer service to ensure that it’s been reviewed and approved.
DAN: I'm going to make an assumption that this process is a little complicated and you may not know whether or not a procedure needed to be prior authorized or not. And so, if you get any questions, I assume you do the natural thing which is call that number on the back of your I.D. card and a medical director can kind of help point you in the right direction and tell you what you need to do. Well, Leslie thanks for being here and thanks for joining us for this episode of Blue Promise. Don't forget to subscribe to the podcast from wherever you listen. You can also leave a review, which will help people like yourself find this content. Thanks for tuning into Blue Promise.
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