Pelvic pain had dogged Keith Morgan for years, unresolved by stretching, hot baths, and other therapies recommended at various doctor visits over the last two decades.
So when the issue flared up last August, the 56-year-old Montgomery County resident wanted to get to the bottom of it once and for all, with a pelvic MRI.
A friend with similar symptoms had recently been diagnosed with a sports hernia after having the scan, and with other causes of his pain ruled out, Morgan thought maybe he had the same affliction.
What seemed like a straightforward plan quickly got complicated: Morgan's insurance plan approved the scan at one doctor's office but denied coverage at another.
A pelvic MRI is among the many services for which insurance companies require prior authorization, meaning that doctors must submit details about the procedure and why it is necessary to get the insurer's approval.
Insurance companies say the process protects patients from unnecessary medical procedures. Doctors, meanwhile, often say the practice is needless red tape that wastes their time and puts insurance bureaucracy in the middle of the doctor-patient relationship.
And any patient who has reported for a medical procedure – only to be told at the last minute that their insurer has denied authorization – knows the communication problem all too well.
Medical and insurance groups have vowed to streamline the process by improving communication between doctors, insurers and patients. Patients such as Morgan, who've been caught in the crosshairs, see the need for faster action.
"There's something flawed here," said Morgan, the former CEO of Aamco, the transmission-repair chain. "You can't have a doctor with a patient in need denied coverage after a physical exam, whereas miles away in the same city a doctor gets approval without even an appointment."
‘I felt bullied’
Thinking the source of his pain could be a sports hernia, a painful soft-tissue injury in the groin area, Morgan paid a visit to a hernia specialist at Penn Medicine. Sports hernias can lead to a traditional abdominal hernia. But the Penn doctor determined that hadn't happened to Morgan, and referred him to William C. Meyers, a pioneering physician in core muscle injuries whose patients include dozens of professional athletes.
Meyers' Philadelphia clinic, the Vincera Institute, told Morgan that the doctor would see him only after the MRI had been completed. The scan could be covered in-network by his insurance, Independence Blue Cross, but if the scan showed he needed surgery, it would likely not be covered by insurance.
Vincera submitted the MRI to Blue Cross for prior authorization and it was approved Aug. 15, according to a letter Morgan received from Blue Cross.
In the meantime, Morgan decided he would rather have the scan at Penn, where he had already been examined and where his other doctors are based.
To Morgan's surprise, the insurer denied Penn's request for the MRI, saying he should first have an X-ray to rule out arthritis, and then have several physical therapy sessions to see whether that could address his pain.
Contacted by the Inquirer, Blue Cross officials said they could not speak to why the MRI was approved through one doctor but not the other, due to patient confidentiality requirements.
The insurer requires such approval for about 1,400 outpatient procedures, with a focus on those at risk of being over-prescribed, such as scans that expose patients to radiation, said Virginia Calega, vice president of medical management and policy at Blue Cross.
"We really, truly — whether someone believes us or not — are trying to look at that patient safety issue in terms of what's the best care and following the evidence-based standards," said Calega, who is a physician.
For services that require prior authorization, doctors answer questions that Blue Cross uses to determine whether a procedure is medically necessary.
If Blue Cross cannot make that determination, the request is denied and a less expensive or lower-impact treatment is recommended.
Blue Cross reviews its list of services that require prior authorization annually and gives doctors 90 days' notice of any changes, Calega said.
Patients and doctors can appeal denials.
After his MRI was denied, Morgan asked Penn to try a second time. Again, Blue Cross denied coverage.
"As an important element of working to ensure continuity of care, Penn Medicine physicians and staff often work closely with both patients and insurers to obtain prior insurance authorization for medically necessary and recommend procedures," Penn Medicine said in a statement.
Morgan decided to have the scan anyway and paid $2,340 out of pocket. He was in pain and wanted to move on to the recovery process.
The MRI showed a torn labrum, a ring of cartilage that lines the hip joint, which required physical therapy to heal.
He brought the case to Philly Health Costs, a price transparency project by the Philadelphia Inquirer and 6ABC Action News, because he was bothered by what seemed like an arbitrary decision and concerned about how someone who couldn't pay cash for an MRI would have fared in a similar situation.
"I felt bullied," he said. "I felt like as much as I was making a valid and reasonable argument, the answer was no — just, no.
"It's almost like a parent telling a child, 'because I say so.' "
A confusing picture
Doctors say that the prior-approval process is frustrating for them, too.
The American Medical Association on Monday released the results of a survey of 1,000 doctors, 84 percent of whom characterized the burden of prior authorization as high or extremely high.
Meyers, who has published papers about his techniques for performing MRIs specifically for diagnosing sports injuries, said he is not sure why his clinic was able to get approval for a scan that was denied at Penn.
"It's a confusing picture for the public and for the providers," Meyers said. "We don't have any special insight."
In January, several industry groups, including the American Medical Association, American Hospital Association, America's Health Insurance Plans, and Blue Cross Blue Shield Association announced plans to improve prior authorization.
The agreement calls for routine review of which services require prior authorization, reducing reporting requirements for doctors who meet quality metrics and improving communication to reduce delays in getting patients care they need.
"Our goal is to streamline the process," Cathryn Donaldson, a spokeswoman for AHIP, said in a statement. "Together, we will help patients have timely access to safe and affordable care, while reducing administrative burdens for health-care professionals, hospitals and health insurance providers."
Locally, a Bucks County Republican, Marguerite Quinn, is sponsoring state legislation that aims to speed up the prior authorization process by requiring insurers to make determinations within two days of receiving all needed information.
"We've seen cases where it's delayed patient care and it affects their well-being," Ted Christopher, president of the Pennsylvania Medical Society and chair of emergency medicine at Jefferson University's medical college, said of prior authorization. "I think this will go a long way to helping patients."
Morgan said he's glad he had the MRI, despite the hassle, because even though it was indeed physical therapy that helped him, he wanted to know exactly what was causing the problem. His pelvic pain has subsided, after lots of therapy and stretching, and he is back to a workout regimen that includes time on his home elliptical machine.
The MRI bill, though, is still a thorn in his side.
He appealed the denial and was rejected, though he's still trying to recoup the money. He says he will donate the $2,340 to charity — if he ever gets it.