AMA Becoming Passe – And the Recurring Nightmare of Prior Authorization

Today I have a topic that is quite practical and applicable to the everyday work of readers. Many have discussed the power of our words. The wrong word or phrase can negatively influence the way a patient is treated by others. We no longer say that a patient “denies” a symptom, and we avoid the term “drug seeker.” We are moving away from saying someone is “homeless,” now stating that they are unhoused. People are not “addicts,” but have a substance use disorder. Of course, no one is purposefully using such terms in order to negatively affect a patient’s care, but it happens.

Medical terminology also changes, with the term “congestive heart failure” being replaced by simply “heart failure” or a variation thereof. The disease process that got me my first publication in 1991, “central pontine myelinolysis,” is now called “osmotic demyelination syndrome.” And one of Dr. Erica Remer’s favorite terms – “functional quadriplegia” – did not exist when I was in practice.

For many of these new terms, it is easy to determine the meaning of the term, and our colleagues can interpret that for patient care issues and for coding of claims.  But last week on Twitter, I came across a term that was new to me, although there are references to its use in the recent past in the medical literature. Providers are starting to indicate that patients “left via patient-directed discharge” instead of saying that the patient left “against medical advice.”

This new terminology is certainly less stigmatizing, but at least to me, the meaning is not self-evident. Was the patient given a choice of going home or going to a skilled nursing facility (SNF), and they chose to go home? Or was it determined that their home environment was not safe and they insisted on going home despite the risks, against the advice of the treating team, after being informed of the risks?

Time will tell whether this terminology is used more widely, but it may be worthwhile to spread the word among your case management, utilization review, coding, quality, and compliance staff to be aware. It should be noted that the patient who departs as a “self-directed discharge,” insisting on an unsafe discharge plan, can still be coded as departing against medical advice. To the best of my knowledge, there is no regulatory requirement that the exact words “against medical advice” appear in the medical record.

Of course, the documentation from the physician must indicate that the physician advised continuing hospital care or discharge to a different destination than that chosen by the patient – and that the chosen plan had risks the patient was willing to accept.

As I described in a previous RACmonitor article, coding a claim as “against medical advice” has important implications, and one does not want to miss the opportunity to most accurately report the patient’s course of care.

Changing gears, an orthopedic surgeon recently posted on a social media site for physicians that his 70-year-old patient required a total knee arthroplasty after failure of conservative measures of medication and injections (he did not note if the patient had physical therapy). The records were sent and prior authorization denied, warranting a peer-to-peer call. The doctor himself then tried to make that call, noting that he spent 17 minutes and 27 seconds navigating though the payor’s phone tree before he could talk to a human being. And then it ended up that all he could do with this person was to schedule the peer-to-peer call and not actually do it.

More than 17 minutes just to schedule the peer-to-peer? I know it sounds bad for me to say that doctors’ time is more valuable than others, but it is often true. I am sure even the payers would rather have doctors seeing their patients instead of navigating a phone tree, so perhaps they could have an option (as many pharmacies do) for physicians to bypass the phone tree and be connected directly to a medical director to discuss the case in real time.

Oh, to dream…