Prior authorization continues to delay patient care and treatment, impact outcomes, and drive up health care costs for all Hoosiers. Physician offices advocate for their patients but are forced to waste valuable time and resources on these burdens.

Your stories about how prior authorization impacts patients are a powerful way to help ISMA put Patients Over Prior Auth.

ISMA asks members to participate in its newest advocacy initiative by sending us the latest example(s) of payors inappropriately putting prior auth over patients. Since the short intake form went live, more than 50 stories have already been submitted to ISMA, including:

Erin McDonald, MD, submitted: “I had a patient who presented with progressive shortness of breath, cough, and weight loss several months after having COVID. The patient’s chest X-ray was abnormal, and a subsequent chest CT showed a 4.2-centimeter left lower lobe mass with bilateral noncalcified pulmonary nodules and intralobular septal thickening likely reflective of bronchogenic carcinoma with metastatic disease and possible lymphangitic spread of the tumor. A radiologist recommended a PET/CT. There was notable mediastinal and upper abdominal adenopathy. I referred the patient to pulmonology for biopsy and oncology and ordered a PET/CT. The PET/CT was declined by their insurance because their tumor was not over 8 centimeters, and we did not yet have a tissue diagnosis, despite my peer-to-peer. This patient with Stage 4 lung cancer, which spread into their chest, abdomen, and pelvis, had to pay for their own PET scan.”

Sharon M. Moe, MD, wrote: “An (elderly patient) had progressive CKD and chose not to undergo dialysis, and instead continue to live their life to the fullest they could. The patient was quite anemic, as is usual, with end-stage kidney disease and shortness of breath. They needed injections of erythropoietin, a hormone that is given to nearly all patients who choose dialysis. From order to receipt was two months due to back-and-forth prior authorization for the GENERIC form of this injection. That's two months of their life they could NOT do the few things they wanted to do before passing due to being short of breath. This is just wrong.”

Elizabeth Struble, MD, said: “I have a patient who was on a generic brand of an antidepressant medication. Last year, their insurance required that they, instead of taking the generic, needed the brand-name medication. Unfortunately, at that time, our local pharmacy did not have the brand name available. The patient ended up paying out-of-pocket at a different pharmacy, and in the new year we tried again. I sent the generic, for which the insurance company required a prior authorization. The prior authorization was denied, stating that the patient needed to take the brand-name medication. Once I submitted the brand-name medication, another prior authorization was required. In the meantime, this patient had been without this medication now for over a week. The generic version of this medication was fairly inexpensive, but still more than the patient would have paid had their insurance approved the medication as they had in the past. This unfortunate patient’s situation is still not resolved.”

There is no limit on the number of submissions you can make. In fact, the more examples we have, the more impactful it will be -- even if they are repetitive. This survey is not limited to just ISMA members. We want to hear from as many Hoosier physicians as possible. 

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Patients Over Prior Auth FAQ

What is the current status of prior authorization in Indiana? 
Indiana’s average denial rate for in-network claims by healthcare.gov (marketplace) issuers in 2021 was 23.6% -- the third highest in the country.  Legislative solutions are challenging for various reasons, including because most plans in Indiana are not regulated by state insurance. Indiana is one of the unhealthiest states in the country, and patients need care. Last year, the General Assembly passed a limiting prior authorization in state employees’ health plan, but it’s not enough – Hoosiers need faster progress. 

Why is ISMA collecting these examples? 
ISMA sees a strategic opportunity to bring thousands of physicians, their staff, and patients into working to improve the prior authorization process. To do this, ISMA asks physicians and others to share specific examples of prior auth situations AND suggest solutions to minimize prior auth or make the system more efficient and have better patient outcomes. The public, policymakers, regulators and payors need greater awareness of how much PA is interfering with patient care.

What kind of information is ISMA looking for?
De-identified stories and solutions of prior auth situations, which include explanations of adverse consequences to patients (including those who needed emergency care as a result of delays or denials, thus increasing costs) and explanations of the time and effort expended in trying to navigate the process.

Why ask about the type of insurance and payor?
ISMA hopes to collect not only stories and solutions, but also the organizations involved to develop a more complete understanding. This information could help ISMA identify inconsistencies between both plans and payors.  Only certain types of plans are subject to state regulation.  

How do I share my story?
ISMA has set up a web form with a few open-ended questions and several queries to help us categorize prior authorization stories by payor, medical service, and member status. This link may be shared with nonmember physicians, physician staff, and patients/caregivers.

How will this information be shared?
If enough stories are gathered, issues identified, and possible solutions put forth, ISMA intends to take physician input directly to payors and regulators to look for ways to improve the prior authorization process for all.  ISMA will share individual names with other members but not with payors absent express permission from the physician. ISMA intends to share the stories with payors on a regular and rolling basis with the goal of working together to address some of the inappropriate barriers to care.

Why do you ask for my name then?
There may be opportunities to share individual names of physicians with legislators if a member is in their district as a constituent, in order to make connections between lawmakers and ISMA members. Legislators routinely tell ISMA staff that personal connections are key to sharing information on complicated issues such as prior auth.

How will we know if progress is being made?  How long will it take to see results? 
ISMA will publish updates about this initiative, including advocacy efforts and results. How long it takes to see results depends on how aggressively the General Assembly, the regulators and the payors want to address the issue.  That’s why it is important that physicians continue to send stories for us to share to keep the attention on this issue. 

Thank you to the following physicians who have shared their names and stories with ISMA, and the dozens of others who have chosen to remain anonymous. 

Jeffrey Barr, MD Scott Curnow, MD Cassandra Curtis, MD Carrie Davis, MD Diane Donegan, MD Jana Sapkar Dukleski, MD John E. Francis, MD, FACS Allon Friedman, MD Teresa Greiner, MD Brittany Huynh, MD  Dorothy Klingmeyer, DO William Marcrum, MD, FAAFP Erin McDonald, MD Andrew M. Miller, MD  Sharon M. Moe, MD

Douglas Neeld, MD Tamara Nelson, MD  Ann Patterson, MD Christina Pinkerton, MD Sarah Perryman, DO  Matthew Priddy, MD Walter Roberts, MD Andrew Skinner, MD Elizabeth Struble, MD  Gregory Swartz, DO Rachel Trupe, MD  Carolyn Warner-Greer, MD Danielle Wiese, MD Chris Wilson, MD Margaret Zelasko, MD