Physicians — and their patients — are justifiably frustrated when delays in getting financial authority interfere with the timely provision of medical services. But health care providers need to be careful that they do not become part of the delay.
A 20-year-old skateboarder fell and injured his right elbow on a Friday. X-rays taken at the emergency department revealed a fracture of the radial head. On Monday, the young man saw his regular pediatrician, Dr. P, who concluded that her patient needed to see an orthopedic surgeon. The next day, Dr. P’s office submitted an authorization request to her network for a consultation with an orthopedic surgeon, Dr. OS.
That request was approved by the network’s managed service organization (MSO) 14 days later and the patient visited Dr. OS nine days after that. Dr. OS noted that the patient had a comminuted fracture of the right radial head with displaced fragments. Dr. OS noted that the patient “requires excision of radial head and bone fragments” and faxed his report to Dr. P with a note: “This patient needs a surgery. Please get an authorization for his surgery and fax it to us so we can schedule him. It will be done at [Community Hospital]… Please do it ASAP.”
As it turned out, Dr. P did not request the surgical authorization until 15 days later. By that time, six weeks had passed since the injury.
The next day, Dr. P received a fax from the MSO indicating that the approval status was “deferred.” More than three weeks later — now nine weeks after the patient’s fall — the surgical request was denied because of lack of records.
(The MSO later claimed that it had sent to Dr. P a request for Dr. OS’s medical records — though that request does not appear in Dr. P’s records nor is there a verification of such a fax transmittal.)
When the patient finally saw another orthopedic surgeon three months hence, that surgeon wrote: “It is clear that this patient was absolutely mismanaged from the beginning. He suffered a right radial head/neck fracture, which appears to have been severe. It has since healed in a malunited position resulting in forearm synostosis and debilitating loss of function and strength. The injury should have been treated with urgency with ORIF… followed by immediate physical therapy to regain range of motion… The failure to adequately provide correct treatment for this patient has directly resulted in a negligent outcome and essentially permanent loss of function and permanent disability.”
The patient later received physical therapy and sued Dr. P, the network, the MSO and the health plan for his permanent injuries. As to Dr. P, the patient alleged that she was negligent in the 15-day delay in requesting the surgery recommended by Dr. OS and that she negligently did not forward the medical records sought by the MSO.
Dr. P, the MSO, and the patient resolved the matter informally prior to arbitration.
Just as physicians have detailed systems in place to follow up on critical medical referrals and tests, so should they treat financial authorizations for needed medical care. Though health care providers and payers participate in increasingly complex arrangements, it is still the physician who has the primary responsibility to diligently act in the best interests of the patient.
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc. (CAP).
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.