for Us to Be Good Stewards of Your Money
I’ve been involved in church management for decades; I’m used to hearing “steward” or “good steward” thrown around a lot. I recently realized I never looked up any real definition of the word. I did, and I found five different definitions in the same dictionary. The one that resonated with me:
Steward: “A person employed to manage another person’s valuables or property (or estate)”
This got me immediately thinking about us here at Louisiana Blue. And it also got me thinking about you, our members who trust us with so much. In a typical year, Louisiana Blue pays for over $8 billion of medical services and medicines on your behalf. We do this through money we take in via premium payments you entrust to us. We are proud that Louisianians have trusted us with this responsibility for more than 90 years. Working every single day to continue being worthy of that trust for decades to come is a big concern of our entire organization.
This might prompt you to ask, “Well, Mike, if Louisiana Blue’s employees are managing that much money every year, what kind of tracking and controls do you have in place to make sure it’s being spent properly?” And you would be perfectly correct to ask such a question.
One of the critical controls we have in place to make sure YOUR MONEY is spent properly is a system called prior authorization. I recently talked about the prior authorization process with our Senior Medical Director, Dr. Larry Simon. And I learned some striking facts about the way Louisiana Blue handles this.
You’ve probably heard bad things about prior authorization from policymakers, healthcare providers or in news reports bashing this process. In general, most people think prior authorization is a time-consuming, complicated pain point. But the Straight Talk is, prior authorization is important because we use it to protect our members and keep costs in line.
I am going to share my takeaways from talking with Dr. Larry in a two-part series. Today, I’ll explain why we use prior authorization. Next, I’ll talk about some initiatives Louisiana Blue is leading to make the process less burdensome for everyone involved–the patients, the providers and our care team.
Why Is Prior Authorization Needed?
One of the most common complaints I hear about the prior authorization process goes like this:
“But Mike, if my doctor says I should have this treatment/pill/procedure, why doesn’t Louisiana Blue just pay for it? Why should my health insurance need to review this?”
As a member, I get it! I’ve been there myself. No one likes having to wait for care or spend time working through paperwork, making phone calls to the doctor’s office or rescheduling appointments. But I can assure you that, while sometimes inconvenient for us as patients, prior authorization is in place for very specific reasons that revolve around keeping you safe, keeping your health insurance affordable and maintaining educational partnerships with all the healthcare providers in the state. We want to make sure they have the latest and most timely data on the healthcare they provide.
Some medical procedures, treatments or drugs are so expensive, important or unusual (and occasionally overprescribed) that we want to take a second look and make sure this is really the best type of care for your situation before we pay out a bunch of your money to cover it.
I want to be clear that it is not our job to get between any patient and their doctor. But there are cases where we may need to consult with your doctor to help determine if it’s right for us to spend your money on certain treatments, pills or tests. These consults with healthcare providers who are actively treating patients are hugely valuable to us. We learn as we go, just like everyone else.
Why Would Louisiana Blue Say No to What Your Doctor Orders?
In a recent year, Louisiana Blue processed 42 MILLION requests for payment by medical providers and pharmacies on behalf of our members. In that same year, only 14,000 of those payment decisions were denied and appealed for various reasons (that’s 0.03%!). And about one-third of those denials that were appealed, upon closer inspection, were ultimately paid.
Why would Louisiana Blue not approve a treatment? Sometimes, it’s simply because what your doctor is ordering is not covered in your policy. Typically, for something to be covered, it needs to be medically necessary or meet other specific criteria. The types of treatments covered can vary depending on your health plan and the information your healthcare provider shares about your specific medical needs. Employer groups that contract with us to administer their benefits–also called self-insured groups–can make their own decisions about what’s covered on their members’ plans, too.
When a denial happens in the prior authorization process, per Dr. Larry, it’s usually a matter of needing more information. That could happen for a variety of reasons:
- Your medical records don’t show any documented conditions that align with the recommended treatment.
- There are safer or more effective treatment options that may not have been considered.
- Your provider is leaning toward an expensive treatment for that condition when other, equally effective but less-expensive treatment options are available.
As good stewards of your money, it’s our obligation to check into things like these before we agree to pay for something. And as shown by the numbers, we can often reach an agreement with providers once we’ve all had a chance to look at additional information by working together through the prior authorization process.
Who Makes Prior Authorization Decisions?
Another concern I often hear is that “insurance company employees shouldn’t be making care decisions.” And you’re right. MBAs like me should not be making those decisions. That’s why at Louisiana Blue, prior authorization decisions are all made by our in-house team of clinicians.
Dr. Larry assures me that the Louisiana Blue employees involved in prior authorization decisions are doctors, nurses, pharmacists and other clinicians.
Louisiana Blue employs more than 300 people with clinical degrees, training and experience. Many of them joined Louisiana Blue after working in clinical practice, treating patients and experiencing the provider side of prior authorization. These folks spend tons of time researching the latest data and treatments to see best practices for patient safety, clinical effectiveness and care quality. Every prior authorization decision they make is evidence-based, which is a fancy way of saying they use this research, their experience and collaboration with other providers in their decision-making.
We have the data and experiences of millions of patients and their encounters with treatments available to us, along with a large clinical staff that is focused on research and data to know the latest best practices and evidence-based recommendations. This gives us better information about what treatments are safe and effective overall than what’s immediately available to many practicing clinicians.
Many doctors, nurses and providers do not have the time to do this level of research amid treating patients, so this is value that Louisiana Blue’s care team brings to the prior authorization process. We work hard to share our information with medical providers at every opportunity since we’re working on behalf of shared customers–their patients, our members.
The Straight Talk is, here at Louisiana Blue, making sure your care is appropriate, timely, safe and high-quality is our top priority. And prior authorization is an important way we do that.
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