.jpg?n=3004)
After a health’s plan peer-to-peer review maintained the determination to deny a San Antonio vascular surgeon’s request for prior authorization, she says she did the only thing she felt she could in her patient’s best interest: intervene without guarantee of payment.
The patient faced the prospect of losing a foot while Lyssa Ochoa, MD, navigated a prior authorization denial for a procedure she says she typically gets approved “right away.”
“I’m an independent surgeon in private practice, and I work in the most underserved areas of San Antonio. So, I often see patients very, very late in the spectrum of vascular disease,” the member of the Texas Medical Association’s Council on Socioeconomics said.
Dr. Ochoa says she received notice the prior auth request for the surgical procedure would be denied despite the documentation her practice submitted as evidence of medical necessity, including documentation from a physical exam and subsequent test. Shortly after receiving the notice, Dr. Ochoa requested a peer-to-peer review, which the payer provided before the denial was issued and – as required by a TMA-supported state law – with a physician in the same or similar specialty.
As a result of that peer-to-peer discussion, Dr. Ochoa learned the insurer (or its utilization review agent) had attributed the patient’s condition to an entirely different diagnosis and therefore denied her request.
Dr. Ochoa went forward with the procedure and was able to save the patient’s foot – with the prognosis good as of this writing. She is now appealing to recover reimbursement for the service provided.
In addition to holding up critical patient care by questioning the requesting physician’s medical decision-making, Dr. Ochoa says insurance companies’ layered prior authorization processes impose additional costs on practices like hers.
“I employ all my own staff, and to have someone take the time to fight these appeals over and over again can be very burdensome from a time perspective, as well as a financial one,” she said.
Nor is it the first time Dr. Ochoa’s experienced this. About 18 months ago, with a different insurer, a peer-to-peer reviewer maintained the denial of a similar procedure for a patient with a similar foot condition, telling her she needed to repeat a diagnostic test. There, too, she went ahead with that procedure and also appealed to recover reimbursement for the service provided.
In cases like this, Dr. Ochoa’s primary concern is that any delay in a decision can lead to a poorer prognosis for the patient.
“We have a saying in vascular surgery: Time is tissue,” she said. “If we’re not intervening in an urgent fashion in these cases, it puts [patients] at risk for amputation.”
Check out TMA’s prior auth educational sheet for more information about the process and steps to take when a prior authorization is denied.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.