Why I Work For A Prior Auth Company

It's for mostly the reasons you think.

Sorry for the repost. Let me explain. I have a boss. I had told my boss that if I write about specifics of what I do in my prior auth job, I would run it by the comms folks. This was the deal. I did not hold up my end of the bargain. I suggested I just take it down completely. However, they actually liked it but wanted to make some changes. None of what they suggested changes the essence of what I wrote. Those that think that this is censorship would be incorrect - it is in fact guidance. I am lucky that I work with a company that allows me to speak as freely as I do. So, after a few changes, it is back up.

---

I saw a thread on the Student Doctor forums about why doctors would choose to do this type of work. Here is my answer.

I’ve worked in prior auth for about 1.5 years now. At the beginning, I was extremely defensive about it and always trying to justify why I did it, but as time passed, I was proud of the work I was doing. I found that when I talked about it with friends, at least 10 people that have told me how much they hate prior auth have asked me if we were hiring.

So, here is my journey to getting there …

What/How/When/Why we get paid is of significant interest to me. I was an economics major and remain deeply invested in how the economy works, particularly health care. American health care is a complicated mess and one that is enormously captivating to learn about, but also maddening. I have always been interested in “how the sausage is made”, so I decided to figure out how best to learn more. Because I am in the ranks of underemployed radiation oncologists, I started looking for part time options to learn something new, develop expertise in another area and to generate additional income. I came across the company I now work for. I looked at the website and they were doing some very interesting things with digital health, but the core of the company was prior authorization. I interviewed with the team and found them to be intelligent, driven and kind people. The CMO told me that the philosophy was “how do we get to yes”. That sounded refreshing, however, it also sounded too good to be true.

I completed training and within weeks was on the laptop reviewing cases and conducting P2Ps. I recognized so many names and at first, that was deeply uncomfortable due to shame I had with being involved in this industry. But, many people who knew me (and the ones that did not) found that I had done thorough reviews of their cases, provided evidence and also listened. I took the extra time to have them send me PMIDs of relevant supporting articles, occasionally I would review images with them. Often times, the cases did not fit an ASTRO or NCCN guidelines or payor policy. The physicians may not have treated the way I would have, but as long as it met community standards, I would approve. When cases were very difficult and I spent hours trying to figure out what was right, I was told by my mentor / boss that if I spent more than 15 minutes thinking about it, I should give the doctor the benefit of the doubt and approve the treatment. Since I always call with my cell phone, I tell the doctor that if they have a case in review with us in the future to just text me or call me to let me know so I can expedite. If I missed them on the initial call, I would leave my cell phone number so they can reach me when was convenient for them. This flexibility was appreciated.

The nurses, case-review specialists and billing/coding experts that I work with are remarkably knowledgeable about radiation oncology. My supervisor is a woman with a nursing background and she is kind, deeply invested in us doing high quality work and responsive to my needs. My medical superior, the CMO, has become a confidant and someone who I speak to about many non-prior auth related issues, career advice and even parenting tips. The company has virtual baby showers, trivia and our quarterly meetings / town halls are actually very fun. This week, I received a present from the company - Harry and David pears and other snacks (if you have not had their pears, stop what you are doing and order them!). There are clinical refreshers, there are opportunities to teach and I have become involved with sales/development team. That is becoming most interesting to me - how to bring a product that I love to more patients and providers.

Yes, I said it. I love what we sell. Prior auth exists. It is not going away any time soon. In my experience, it is generally awful. Yet, I have received such kind messages from doctors even after I modified or denied a case - “thanks for making this a real P2P'“. I have been taught by faculty new ways that we are treating and am able to thank them for that, so we can update our regimens. I was told by a chairman of a large department who I tried to help increase his reimbursement for a specific case “this was the best P2P I have ever had”. With the leadership of the nursing managers, we have streamlined many processes and included many cases on “auto-approval” that used to be reviewed (wo examples are IGRT, IMRT for most curative cases - two things that clinicians hate fighting us about). I’ve had productive conversations with academic physicians that utilize protons to help us develop a patient friendly, but also evidence based rationale for allowing these treatments. We also will approve proton therapy patients on randomized trials. If you are willing to do the work to increase our knowledge and help patients, we will do our part.

Well, what about the money? It’s pretty good! I am happy with the income boost. My compensation has nothing to do with how many cases I approve or deny. Unless I ask, I don’t know which cases have gotten overturned on appeal (but I did ask and I found very few; they follow a specific pattern; without giving details thank ASTRO for demanding that we Choose Wisely). Do I need the money? Eh.. I do fine, but I have no opportunity at my clinical job to increase my workload and earn a bonus. I have a bonus clause - there is just no way I am reaching it, because the volumes remain very low.

Is it stressful? I have been yelled at once during my first week on the job. I regret what happened - but I learned from that experience. We are not one of the larger companies that have strict internal guidelines that are not based on ASTRO or NCCN, so palliative cases can be tricky. Competent reviewers with clinical experience realize that palliation is complex and also deeply personal. What may seem like extra fractions to some is standard of care to many. I learned from that call that I have to have a broad understanding of palliation evidence, but more importantly, palliation practice variation. This is where I think many of the other companies fail patients and doctors. I got yelled at another time, but they were in the wrong doing something egregious (without giving away the details, think of it as something akin to giving 60 Gy in 60 Fx BID for a curative post lumpectomy breast case - I actually see this quite a lot!). Most of the time, it’s actually fun. People already know my name and my work, so they consider me an old friend and we chat. Some have become friends - seriously!

It has been a great experience. I truly enjoy it. I continue to learn every day. As long as the company keeps me, I will be here. I will continue on making our authorization process transparent, evidence based and patient centered. Next time I call you, we will be discussing “how to get to yes”.

Love you all,

Sim.