1) Patient with new metastatic disease. Evidence-based treatment recommended.
2) All documentation collected and submitted with with published evidence as part of Prior authorization.
Aggregate provider time: 35 min
4) Team calls insurance. Insurance 'mis-coded' original treatment, thus cancelling. Need new submission.
5) New submission completed w all requested documentation
Aggregate provider time: 1hr 15 min
7) Request cannot be escalated without additional documentation
8) Additional documentation faxed.
Aggregate provider time: 1hr 45 min
-Evidence based treatment
-Outstanding clinical team
What happens if all pieces of the puzzle are not perfect?
Simple answer: NOTHING
-Patient is lying awake worrying because there is not a clear plan of care.
-Providers are lying awake worrying about their patient worrying (and/or insurance denial)
-Clinical team is powerless to pursue evidence based therapy.
-Decision #1 may take 5-7 days
-If denial #1, require written appeal
-Decision #2 may take 5-7 days
-If denial #2, require peer to peer
-Peer to peer only available at specific times and requires MD, so takes another 5-7 days
WE HAVE SEQUENCED THE HUMAN GENOME.
WE HAVE IDENTIFIED MOLECULES SMALLER THAN ATOMS.
HOW IS INSURANCE PRIOR AUTHORIZATION THIS HARD!?!?!?