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Pearls From: Mary Norine Walsh, MD

Pearls From: Mary Norine Walsh, MD

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Those physician-to-physician phone calls required to get insurer authorization for cardiac imaging tests, among many others, aren’t just a time-sucking nuisance. They can be a patient safety issue in some cases, says American College of Cardiology President Mary Norine Walsh, MD, of St. Vincent Medical Group in Indianapolis.

In addition to documenting experiences with prior authorizations using the ACC’s Prior Authorization Reporting (PAR) tool, she recommends not backing down.

“We really have to advocate for our patients,” Walsh says in this exclusive MedPage Today video interview, “by not changing our mind about doing an indicated test but rather to go forward and engage this physician who is working on behalf of the insurer and really make certain that it’s well known that these are indicated tests that our patients need.”

A transcript of the interview follows:

The issue that we’re facing more and more in cardiology — also other fields, but I will speak only about cardiology — is the requirement that many payers now have, insurance companies, for us to get on the phone and speak to another physician before they will authorize payment for a in particular an imaging test for one of our patients. These tests include stress echocardiogram, SPECT myocardial perfusion imaging, CT scan, and now most recently we’ve even seen with rest echocardiograms.

So many insurers are now kind of putting a barricade in front of the patient really in having an indicated test by asking the doctor to speak to another doctor on a phone call, in essence to fight to have this study done for this patient. These are not studies that are not indicated. These are for, in the case of my patients, heart failure patients who need to have their left ventricular ejection fraction reassessed because they’ve been on guideline-directed medical therapy for several months. And the guidelines recommend that we reassess ejection fraction before we take the next step, be that a device or other therapy.

So the barrier to this has been that in the office we are frequently are faced with the fact that on a given day that the test is scheduled, we have to then put everything down and talk to another physician on the phone. So the ways we’ve chosen to deal with this in our practice is to do it for every patient every time and really challenge this process by getting on the phone and really going through the guidelines with the doctor on the phone.

One of the things the American College of Cardiology has done is to provide us with a tool called the PAR tool that we can use. It takes about 2 minutes to fill all the data out on what our experience was in trying to obtain this guideline-indicated test for our patient so we can better get a set of data saying exactly what’s happening in different parts of the country. So I think this is something that patients don’t know a lot about, because their doctors and nurse-clinicians are doing it behind the scenes. But, in some cases, this is actually a patient safety issue, where we can’t really move forward with patient care until we achieve the approval to get this study done.

So I think advice to other clinicians out there: We really have to advocate for our patients by not changing our mind about doing an indicated test but rather to go forward and engage this physician who is working on behalf of the insurer and really make certain that it’s well known that these are indicated tests that our patients need.


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