Amid the push and pull on prior authorization, reimbursements and post-procedure clawbacks, three physicians joined Becker's to discuss what's missing in conversations with payers.
Editor's note: Responses have been lightly edited for clarity and length.
Ramanujan Samavedy, MD. Gastroenterologist at Gastrointestinal Associates (Knoxville, Tenn.): I will say the main thing in our conversation with the payers is that the prior authorization for medications and procedures is not streamlined. They are not consistent and do not necessarily follow the medical society guidelines. For example, well established indications for procedures are sometimes denied. The medications in formulary at times are changed randomly and not approved even when they have been covered for years before. This includes generics as well. Lastly, payers claw back even 6 months later, on things that were pre-certified and approved previously. This places undue financial burden on the patients and the providers.
Eric Esrailian, MD. Clinical Professor of Medicine at UC Los Angeles: Continued reductions in reimbursement will negatively impact access to care in the community and have public health implications.
Ravi Krishnan, MD. Ophthalmologist at The Eye Institute of Corpus Christi (Texas): Firstly, what conversations? As far as I'm concerned, it is more of a one-way dictum on part of the payers. We as physicians have very little, if any, opportunity to speak with payers. If we are lucky, I get to speak to a "claims specialist" to argue about why I am not being paid. There is some so-called negotiation of the payment schedule beforehand, but as an owner of a small solo practice, I have very little bargaining power. Maybe some larger practices or tertiary medical centers have better luck, but down in the trenches, I am forced to accept whatever fee schedule is put before me, i.e., "take it or leave it." Our healthcare system is under the mistaken belief that costs can be contained by reducing reimbursements to physicians, and continues to nibble away, making it increasingly difficult to run a practice as an independent physician or owner. I think the only solution is to allow physicians to unionize. I feel that would allow for a more reasonable discussion with payors. Frankly, I do not understand why we are not allowed to unionize, especially in this current day and age, when over 70% of doctors have now become employees. One of the arguments against a physician union is that ours is an "essential service," but so is nursing and so is air traffic control for that matter, and both of those professions have unions.