--"Why on earth does some company have to give me "prior authorization" for my scan?"
--"Do these people get PAID to deny requests for testing?"
--"What if there's something there that I don't know about and my request was denied for a scan anyway?"
When seeking care for your health, hearing the word "no" can be a frustrating and frankly scary experience. The process of Prior Authorization helps to mitigate excessive treatments that may cause more pain and suffering than is necessary to solve a medical question. In this process, medical professionals analyze a request for imaging, and provide a second opinion for the treating provider to help avoid excessive or unnecessary testing for the patient. More often than not, we want to take the "better safe than sorry" approach to our healthcare, trying everything and anything that our doctors suggest might help with what ails us. But, do we ever stop to consider that the "safe" part is what might actually make us "sorry" in the end? What if a suggested treatment worsens the condition in the end? What if we end up with a totally new problem stemming from the dramatic measures we started with to discover the root cause of an issue (rather than a more conservative approach)? What if something suspicious shows up on a diagnostic scan, and your doctor feels compelled to test what turns out to be nothing (and unrelated to your previous complaint)—costing you hundreds, even thousands, in unnecessary medical spending?
For those of you reading this and thinking, this sounds exactly like what I'm concerned about right now, we ask you to join us for a few moments as we explore what a world without prior authorization for these tests might look like.
Alternate Reality #1, John Doe's Back Pain
John Doe visits his doctor's office complaining of low back pain. His doctor then orders an MRI of the lumbosacral spine to try and see what might be causing John D's pain. What he doesn't tell John is that these tests often see things unrelated to his pain, benign issues that would otherwise have never caused him any trouble—and this imaging test will see all of those as potential areas to treat. Since they're still not sure IF those issues are related to John's pain, his provider will treat everything that shows up just in case it's related to the cause. John now spends much more time and money treating an issue that may have had an easier and simpler solution. In addition, as a result of undergoing this particular advanced imaging test, test, John is SIX TIMES more likely to receive a recommendation for surgery, whether or not there's a reason to believe it will help his low back pain subside.
Alternate Reality #2, Richard Roe's CT Scan of the Chest
In Richard's case, he requested his doctor perform a CT scan of his chest to look for tumors in the lungs or anything else that might seem awry. Richard is not a smoker, but he's had the occasional cigar. He's heard that they'll check your lungs if you ask, so he thought, what could it hurt? When the scan is performed, a few spots appear on the x-ray, and the radiologist recommends several pet scans and probing biopsies looking for tumors. They also saw a dark spot in his upper digestive tract, so additional testing is recommended by his doctor. As it turns out, the probes don't feel too good, and they're very expensive. Richard's doctor isn't surprised to learn that nothing seen on the scan was suspicious and that Richard is in good health. Richard is happy with the determination, but his wallet certainly isn't, and the amount of radiation he's now been exposed to is a little worrisome for him.
For both of these men, there were available other options that could have saved them a lot of time, pain, and money, and kept them in better health than the overtesting did. Their fear of a potential problem produced a lot of stress in their lives, and they've got a few new scars to show for it.
Clearly, for certain instances in the healthcare system, prior authorization isn't actually required but the costs in those areas can turn out considerably higher both emotionally and financially. As a patient, you have the right to ask your doctor about alternative options to their first suggestion, and to have a say about what testing you will subject yourself to. If you're not sure about undergoing a proposed test, we hope that these stories help explain why such a test might be denied for insurance coverage as occurs in some prior authorization requests, and why in the end it may be good for you and your health to not seek out and treat every "incidentaloma".
Do you have more questions about why prior authorization is necessary for you? Please feel free to read on for some conservative care options for treating lower back pain.