Authorizations — Part 2
Once again, a little comic relief never hurts anyone. I found another funny video from Dr. Glaucomflecken about prior authorizations. Click here for a quick giggle and then we’ll return to our discussion.
Last month, I wrote my first entry about prior authorizations. You can find that article here. I made the claim that I believe the BUCAs (Blue Cross, United Healthcare, Cigna & Aetna) are using their prior authorization processes to steer care to sites where they have a financial stake in the payment of the care.
In today’s article, you’ll find out why I believe that. In May 2024, my husband was told he needed a pelvic MRI by the provider who saw him when the results from his first PSA test came back a little high. It didn’t seem all that alarming to me, but the practice he goes to wanted it done. As I investigated this situation, the reality became clearer.
While I don’t have direct insight into what his primary care practice was incentivized to do by BCBSNC, we are all aware of the misaligned incentives that exist when RVUs (relative value units) are part of the equation. Seeing a PSA level higher than normal and being incentivized to order more tests was certainly part of the equation that led to this pelvic MRI recommendation.
Without even telling my husband what they were doing, an appointment was made at a hospital imaging center in a nearby town. Curious as to why he was being sent to a hospital system for a pelvic MRI vs. an independent imaging center, I called the practice. What I was told was shocking.
When I posed the question – “why a hospital” for an MRI, I was told “because that’s where his insurance preferred”. What!?! I’ve been told for many years that health insurers with huge PPO networks like BCBSNC don’t steer patients because that would violate their network contracts with every other provider in the network. So, why were they steering in this situation?
One more piece of this puzzle will really make you question everything you thought you knew about the BUCAs. There’s a serious problem with a lack of transparency in hospital pricing. Patient Rights Advocate is practically the only group sounding the alarm about this problem. When I investigated the prices, I found that BCBSNC was steering my husband to the highest-priced pelvic MRI of any site around us. It’s not like they didn’t know it was the highest-priced option. They knew.
It didn’t matter that we had a $ 2,000 deductible, which would have left us paying a huge portion of the charge out-of-pocket. With additional co-insurance, I’m sure we would have been almost 100% out-of-pocket for this image. Writing about these frustrations, the story got picked up by the media. Here’s a quick video from the local Fox News affiliate that adds a little more color to this story.
Bottom line, when BCBSNC negotiates contracts with hospitals, they put their own interests first. I know I’m preaching to the choir here. You can take this to the bank…the BUCAs steer patients to where they want them to go. All you have to do is follow the money. They will steer to the highest priced option, and they don’t care how that affects anyone else. I’ve seen it with my own eyes.
