Survey of St. Louis area doctors finds insurance delays have gotten worse, hurting care

St. Louis Post-Dispatch (MO)

Dec. 23--St. Louis area doctors say it's not easy working with insurance companies, especially when it comes to getting the required approvals for certain services.

A recent survey of local physicians found that their offices are facing longer delays and more severe restrictions for certain procedures and medication due to insurance companies' precertification or prior authorization requirements.

Insurers require physicians to get approvals before rendering care in some instances. It's a way to curb costs and ensure appropriate care is provided. Although it's not a new practice, some doctors say the lag time is growing, costing them additional resources and staff time, which negatively affects patient care.

The survey, which was conducted by Prell Organization, found that more than half of the 302 physicians surveyed "strongly agree" that precertification affects their ability to practice medicine. Prell, a Chesterfield-based market research firm, conducted the survey from September to October.

More than half of the physicians surveyed said that precertification has caused a treatment plan to be altered.

"It takes longer and longer, and we're seeing more and more denials of benefits for patients," said Dr. Samer Cabbabe, a plastic surgeon and president of the St. Louis Metropolitan Medical Society.

When there is a problem that needs to be resolved, Cabbabe said, "we've found it very difficult to correspond with the insurance companies.

"It's gotten progressively worse," he said.

Until recently, there used to be a local insurance company representative to call directly.

"You knew the person, you'd get a hold of them and they figure it out," Cabbabe said.

But that's changed.

Now, most of the time is spent waiting on hold.

And, sometimes it's for seemingly mundane care, said Dr. Ravi Johar, an obstetrician and gynecologist with Mercy.

Johar said he has issues getting certain brands of birth control approved for his patients. But he's confused why precertification is required, because the Affordable Care Act mandates that contraceptives are covered by insurance companies with no cost to patients.

Getting the birth control pill Lo Loestrin Fe approved has proven especially difficult, he said. It does not have a generic equivalent, so insurers don't want to pay full price for the brand name drug.

Johar said he likes to prescribe Loestrin for some patients because it has a very low dose of estrogen. But sometimes insurance companies or prescription benefit managers refuse to cover the brand name when there are other, less-expensive birth control pills.

It's a "hassle," he said. It requires his staff to spend an inordinate amount of time haggling with the insurance companies, and sometimes they won't talk to anyone but the patient.

Dr. Daniel Scodary, a neurosurgeon with SSM Health, said it can take weeks to hear back from insurance companies about needed spinal fusions for patients. And sometimes they'll deny it.

"That doesn't sound like a long time, but if you have a ruptured disc in your back, that's a long time," he said.

For those who need a spinal fusion, usually they've exhausted numerous other conservative treatments such as therapy and shots to dull the pain.

What's frustrating, Scodary said, is that the insurance companies are playing doctor.

At Cabbabe's office, he said it's very difficult to get insurance companies to cover breast reduction.

Then they'll ask a series of questions, including "have they tried multiple bras," he said.

But precertification can help connect patients with alternative treatments, according to America's Health Insurance Plans, an association that represents health insurance companies.

"For example, as prescription drug prices continue to skyrocket, patients can benefit from prior-authorization when there are effective treatments that are less expensive, which can lower out-of-pocket costs for patients," David Merritt, executive vice president for AHIP, said in an email statement.

Dr. Jack Davidson, market medical executive for Cigna in the Missouri region, said he's aware of the local survey.

Davidson said a trouble spot for physicians may be that insurance companies such as Cigna are trying to gather more data to make sure doctors are delivering the appropriate care.

"When we issue an initial denial it's because we haven't gotten enough information or the right information from the physician office," he said. Then it requires a few phone calls to resolve the issue.

He said insurance companies are hired by employers to make sure their health care dollars are being spent appropriately, and precertification is one way to achieve that.

But a study published in 2014 shows that precertification comes at a cost to physician offices.

The study had primary care physician offices fill out a card every time they were seeking precertification. They wrote down the purpose of the precertification, the payor involved and the number of minutes spent on the request.

The study found that offices spend $2,000 to $5,000 per provider per year on getting services precertified.

"These are not negligible costs," said Christopher P. Morley, one of the researchers and interim chair of the Department of Public Health and Preventive Medicine at State University of New York System.

Samantha Liss --314-340-8017

@samanthann on Twitter

[email protected]

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