Opinion: True peer-to-peer conversations will improve prior authorization
It’s another busy day in my spine surgery clinic when my phone rings. Patients are waiting, but I’d be unwise to put off the caller: a physician calling from a health insurance company. This peer-to-peer call is part of the prior authorization process; my “peer” needs information to determine whether the company will cover a procedure I requested for one of my patients.
Sometimes the conversation goes uneventfully. The “peer” and I establish that the service is medically necessary, and it quickly gets approved. But it usually feels like talking to a wall — a distant voice reading scripted questions off a computer screen — and I sense this is a box-checking exercise destined to result in a predetermined denial. Missing is any discussion of the nuances of the patient’s case or the clinical reasoning behind my request, based on more than two decades of clinical practice and the thousands of similar patients I’ve treated.
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