Why does it take so long to get an MRI approved?

The process of getting an MRI for a patient used to involve two things - a doctor who wanted an MRI and a patient who needed an MRI.  A doctor is trained for over 11 years (many specialists are trained even longer) to make the right decisions on behalf of patients.  We use that knowledge and training to decide when an MRI makes sense for our particular patient’s situation.

However, in the past decade or two things have changed drastically and continues to become progressively more complex.  Now getting an MRI involves:

• The patient who needs it
• The doctor who wants it ordered
• The insurance company
• The insurance company’s hired third party non-clinical staff who administrates prior authorizations
• The clinical staff at the third party who reviews authorizations

AND

• The billing administrator at the imaging facility who reviews and ensures authorizations are done by the doctor

​​When a patient needs an MRI, first the doctor (or his or her staff) has to figure out which third party administrator is used by the patient’s particular insurance company.  Once that is determined, the doc has to reach out by phone or submit an online form to request the test.  This includes coming up with special codes for the test, the diagnosis, and explaining everything that has already “been tried” for the patient (i.e. visits, therapy, meds, etc.).  Once submitted, this request undergoes review.  Somewhere around 75% of the time it is rejected or denied for one reason or another (usually an administrative burden - i.e. the patient’s visit date was not entered or the patient’s physical therapy wasn’t submitted correctly, etc.).  Often, the doctor has to then call in and wait on hold for 10-30 minutes to speak with someone who is clinically trained (up until this point the doctor is talking only to non-clinical administrative staff) to argue the patient’s case as to why their patient needs THIS test NOW.  

Once that is all finally completed, an approval is usually given.  In other words, most of the time, these hoops are just hoops, created by insurance companies and third parties for doctors and their staff to jump through, so that maybe some will just back out of the hoops and not jump.  I.e. the insurers will save money because some offices just can’t persist long enough to get the approval.  Which means, some patients who need a test, have to go back to the drawing board and start over - often meaning seeing a specialist for evaluation so that THEY can try to get the approval.  

At DPC practices, like Direct Doctors, while we still have to fight these battles, we are better equipped to navigate this on behalf of our patients because we have more time and know our patients much better.  We care to go that extra mile, even if it is a pain!  We don’t let our patients’ needs fall through the cracks.  To find out how else we practice primary care differently, check us out at www.directdoctors.org.