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Prior Auth Limbo Gets Personal

Posted by Justin Adams on Aug 17, 2018 2:57:50 PM

You all know the statistics—annually, prior authorizations cost American hospitals billions in inefficiencies, chew up tens of thousands of clinician hours with paperwork and peer reviews, and create negative patient financial experiences.

At Digitize.AI, we’re on a mission to use A.I. in the form of our platform, Lia, to help healthcare providers better manage prior authorizations to liberate their clinical teams from mundane work and create a better experience for their patients.

This month, that mission became even more personal for me. Because on Wednesday, August 15th, I was informed that my own medical treatment would be postponed due to a—you guessed it—prior authorization delay.

This just got very real.

Here’s the quick timeline:

  • Sunday, Aug 5th. I hurt my knee playing basketball. Yeah, I’m 35—but I can still make a few moves and drain a few shots. And I’ve weathered a few aches before. But this was different. Lots of pain.
  • Tuesday, Aug 7th. I see one of the top orthopedic doctors in Charlotte. He works with a lot of the professional sports teams—I’m in good hands. He sees one issue in an X-Ray and orders an MRI to rule out other issues. His support staff tell me “schedulers would be in touch,” and I’m ordered not to do any lower body exercise. No hoops for a few weeks. Felt like these guys:

The same frustration faced by athletes and those who work with artificial intelligence and intelligence systems.

  • Friday, Aug 10th. The “schedulers” call and say the soonest MRI they can get me is Thursday Aug 16th. OK, I can last another week.
  • Wednesday, Aug 15th—Morning. The radiology center rep calls to do my intake screening. We spend 20 minutes verbally going through a questionnaire. Tedious, but par for the course, I presume—it’s now been over a week since the doctor issued the MRI order.
  • Wednesday, Aug 15th—Afternoon. Late afternoon, the day before my procedure is supposed to  happen, the “schedulers” call and say the authorization was denied by the insurance company, and they have to send it back to the orthopedist for a peer review.

Here’s the kicker: on that last call, when I ask, “How long will that take?”—since, you know, I still can’t exercise in the meantime—the reply was: “No clue. If you haven’t heard anything by sometime next week, call your doctor and see if he had the time to do the call with the insurance company.”

I’m thinking, Gee, I’m sure my doc has a lot of free time to call the insurance company and haggle with them. No wonder this peer-to-peer thing is such a big issue for physician burnout. This is dumb because it is so easily avoidable.

Of course, I’m grateful that I’m not contending with a more serious illness or injury—a busted knee and a few weeks off the court is frustrating, as is this delay. But I imagine if I had a more serious illness, or if a member of my family were in this situation with a more dire diagnosis, my frustration and confusion would be exponentially greater.

But that is the reality for many patients with dire illnesses every day. And it’s not just the waiting…or the delays. It’s the lack of clarity, and the seeming lack of progress. Prior auths put patients in a limbo that they can’t fully understand but feel intensely. And that feeling is something I now grasp on a much deeper and personal level.

Don’t even get me started on how I feel about my insurance company right now. They have put me in limbo and in a real way affected the quality of my life, all over an avoidable prior auth situation. If I were to fill out a customer satisfaction survey right now on my insurance company, I would give them an “F”. That isn’t taking into account my deductibles or premiums or any of the other things I usually associate with health insurance. They are messing with the quality of my care right now. Shame on them.

I did not foresee this prior auth issue personally affecting me when we built Lia to make the prior auth process more seamless. But now that it has, I am doubling down on our mission.

If you have a similar situation to share, we would love to hear from you. Please send us an email of your experience at PriorAuthsSuck@digitize.ai, or send a tweet with the hashtag #PriorAuthsSuck.

Learn how A.I. and automation make prior authorizations faster and smarter.

Justin Adams

Written by Justin Adams

Topics: AI, Prior authorization, Artificial intelligence, Revenue cycle