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Blue Promise: Ensuring Your Health Care is Effective

DAN: Has your doctor ever recommended
a service or treatment that required pre-approval by your insurer?
What’s the reason behind this? Find out in this episode of Blue
Promise. [MUSIC] Thanks for tuning into Blue Promise,
where we’re committed to addressing complicated health issues with candid
conversations from subject matter experts. Hello, I’m Dr. Dan McCoy. I’m the
President of Blue Cross Blue Shield of Texas. I’m joined in the studio today by Dr. Leslie
Weisberg. She’s our chief medical officer in southwest Texas.
Leslie, welcome to Blue Promise. LESLIE: Thank you, it’s good to be here. DAN: So, why do some health treatments
require a pre-approval by an insurance company? LESLIE: So, typically these health treatments
require prior authorization, which is a request for a medical or surgical procedure or a drug
prescription that needs to be reviewed against nationally recognized evidence-based
guidelines. And we do this to ensure that our members get the appropriate care, in the
appropriate place, at the appropriate time. DAN: So, what determines if a
procedure is going to need a pre-approval? LESLIE: So, typically we focus on
procedures that may be high cost, may have a high risk to our members,
as well as procedures or drugs that may have off-label use or indications that
don’t follow the medical base guidelines. DAN: Give me an example of a procedure
that would be like in each of those categories, like high cost. What’s an example of a high
cost procedure that typically needs a preapproval? LESLIE: So, typically an example would be
a cervical fusion. That’s a high cost procedure that we have medical policy guidelines
about that would require a prior authorization. And the prior authorization looks at things
such as surgeries, has the patient failed conservative therapy, have they tried alternate
measures? To ensure that we’re giving our patients or helping our patients, I should say,
get the most appropriate and effective care. DAN: Okay, so you’re going to have to help
me out here. So, what’s a cervical fusion? LESLIE: So, a cervical fusion is a procedure
on the spine that is performed to help relieve back pain, neck pain, as well as sometimes
things such as numbness or tingling in the hands. DAN: Okay, so does that also play
a role in patient safety too though? LESLIE: Yes, it does.
Because by doing procedures such as that, that the physician has not attempted
conservative measures for the member. These do have potential complications,
although they would be unintended. We just want to make sure that they’re getting the
procedure and they follow through to meet the criteria. DAN: OK. So, what do the medical directors and
insurers usually look to, to provide the guidance, if you will, in making a determination if
something should be pre-approved or not? LESLIE: So, the medical directors rely on
our four hundred and seventy-five plus medical policies and these policies are reviewed on
a yearly basis, sometimes more frequently if there been significant studies done that
showed that we need to update the policy more frequently. And these policies are based on
evidence-based medicine. So, they look at the medical literature available and base it on large
randomized controlled studies. And so, in this way we know that in a large cohort or population
of individuals, this procedure, test, or drug has shown improvement in a large number of
patients. So that’s what the medical directors use. DAN: But why can’t you just rely
on your doctor to make that decision? And why do you need to look
at evidence-based medicine? LESLIE: As a health care practitioner
in 2019, there’s a lot to keep up with. And so, sometimes a doctor may not
always be aware of a recent change or update in the medical literature. Or sometimes he
or she may think that a drug that is used for one indication or say may also be
used for an off-label use when again, it doesn’t have the criteria or data to support it. DAN: So, it sounds like to me that you have
a team of people that are actually looking at this information. So, are these policies updated on
a regular basis or how often do you look at the literature to make a determination if maybe
a pre-authorization needed to be revised? LESLIE: So, the prior authorization list is
updated on a yearly basis. So right now, the 2020 prior authorization list has been
reviewed and confirmed. Beginning of 2020, we start preparation for 2021 prior
authorization list. And then with regards to the policies, the medical policies,
those reviewed on a yearly basis and updated. DAN: Okay. So, it sounds like when we
start talking about prior authorizations and you know your doctor’s decision being
questioned, that could seem at least like it’s a cold kind of business decision that has to
be made about often a very emotional time for a patient, who’s struggling with a health
care issue. Tell me a little bit about the process that the member can experience when
going through your prior authorization, why it’s necessary, and maybe some
things that we try to do to make it better. LESLIE: So, the prior authorizations are
necessary to ensure again that members get the appropriate care or the appropriate
drug. It’s important to have prior authorizations so that members don’t have unintended
complications from drugs or procedures that are not medically necessary. So,
that is something that we feel is a very important reason why we continue with the
prior authorizations. With regard to other reasons to continue with the prior authorization process,
is that it also helps to prevent fraud, waste, and abuse. And this can also result in increased
premiums for our members, if we’re approving care that is not medically
necessary or that is considered fraud or waste. DAN: So, in that example, maybe the
patient or the member may not even really realize that this procedure is sort of at risk for
fraud, waste, and abuse. Give me an example of that? So, what’s an example where prior authorization
could maybe prevent a fraud from occurring? LESLIE: So, an example would be the use of
injectable amniotic membrane fluid for different orthopedic complaints such as
fibromyalgia or shoulder or back pain. DAN: So, I guess there’s no evidence-based
medicine for those kinds of treatments. LESLIE: There is not, and, in all
indications, it would be considered experimental, investigational and unapproved. DAN: So, maybe the patient’s going
through a painful procedure for no real evidence-based benefit. So that’s an
example where prior authorization maybe steps in and prevents something that’s
both, not necessarily helpful for the patient, but also maybe have some
fraud, waste, and abuse to it as well. So, are there any exceptions to this process? LESLIE: So, exemptions, certain types of
items don’t require prior authorization. The lists are posted on our
Blue Cross Blue Shield Texas website. So, we encourage providers and
members to always check that. Emergent procedures, so if you have to go
to the hospital for an appendectomy or other type of emergency procedure, you do not
have to be prior authorized. If the inpatient stay for a longer period of time than that,
those days would need to be prior authorized. But typically, emergent conditions
do not require prior authorizations. DAN: So, the other thing I think too is that
people tend to focus on procedures. And we certainly have, in Blue Promise
today, we’ve talked about all these different procedures that people can get. But I
would suspect, knowing where the cost trends are today. Which I remember,
when I started at Blue Cross about four or five years ago, the amount that we
spent on pharmaceuticals was like around 10 percent of a premium dollar.
Today, it’s over thirty one percent of a premium is spent on drugs. I suspect that drugs
play an increasing role in prior authorization too. LESLIE: Definitely. Our specialty review
pharmacy has continued to increase the number of drugs that are on the prior
authorization list for review. An example would be something like intravenous
gamma globulin.That particular drug does have a lot of evidence-based
indications such as for individuals that are immunodeficient. However, it also has
a number of, the reason why it requires prior authorization is because it’s also used off-label
for a number of indications which are not always supported by the medical
literature. It’s a very expensive therapy and usually given multiple times over the
course of an individual’s lifetime. That’s why it’s important for us to prior
authorize or review drugs like that. DAN: So, this growth and the cost of drugs
is really and also the number of drugs to, which are very complicated, I suspect
too. So, they kind of fit both your criteria. They are both expensive and these new drugs
that are coming out have very specific indications, they’re very complicated to use, things of
that kind of nature. I recently became aware of a member issue and it kind of
came to me that this person was going to have a C.T. scan tomorrow. And they were
really concerned because there was a prior authorization pending. And I think I
even reached out to you about that case and said, “Hey, so, what’s going on?:” And
what we found was is that the physician hadn’t even submitted the prior
authorization. So, what are some things that members can do to help their doctor
navigate this process too. Because it is a little bit of an issue that the physician has
to be involved in. What could we do to help them? LESLIE: So, I think that as members, what
they can do to help the physicians is to, before they leave the office, know what is
going to be done and then make sure you check with the office before going through the
procedure to make sure that that prior authorization has been submitted and approved.
If it’s something that needs to be done emergently, they can always submit it as
an emergent prior authorization, so the turnaround time for approval, or I should
say review, will be much quicker. I think that members would want to work first
with the physician ordering the test to make sure that that was submitted. And then the
member or the physician can contact customer service to ensure that
it’s been reviewed and approved. DAN: I’m going to make an assumption that
this process is a little complicated and you may not know whether or not a procedure
needed to be prior authorized or not. And so, if you get any questions, I assume
you do the natural thing which is call that number on the back of your I.D. card and
medical director can kind of help point you in the right direction and tell you what you
need to do. Well, Leslie thanks for being here and thanks for joining us for this
episode of Blue Promise. Don’t forget to subscribe to the podcast from wherever
you listen. You can also leave a review, which will help people like yourself find
this content. Thanks for tuning into Blue Promise. [MUSIC ENDING]

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