Emergency Department Staff Shocked by Prior Authorization Request

CHADRON, NE – Emergency room physician assistant Chester Preshuns was shocked last Thursday afternoon during transport of his STEMI patient to a cardiac/cath lab capable facility. “I knew even before I got the chemistries back this guy had an inferior infarct. II/III/AvF ST elevation, with reciprocal lead changes in I and AvL. The nurses did a phenomenal job getting that within our 10 minute window. I had a cardiologist on the horn in Rapid City South Dakota ready to take him in 15 minutes. Chopper in the air, a nurse was getting bed acceptance with the house supervisor. And…. Well then another line in the ED rang. It was this guy’s insurance company.”

Nurse Ramona A. Carlson took that call. “I was trying to get what labs we already had printed off, the EKG, vitals, all into the envelope for the flight crew when the phone rang. The caller identified themselves as a representative with Profit Margin Health of Nebraska; she needed to speak to Mr. Preshuns about a prior authorization requirement. I told her she needed to hold he was speaking with the cardiologist about transfer. I thought it was strange, but ok, hold please, and I went back to getting the packet ready.”

Chester remembers the call well: “I got off the phone and asked the nurses to get a second line for a heparin drip, and one came over and told me I had a call on hold. I mean, I just talked to the cardiologist then the hospitalist, who else could need to talk to me? Time is heart, so I scrambled back to my desk to take it.” Chester was flabbergasted at the discussion he had next. “The woman says before we can transfer via helicopter we needed to complete a prior authorization and started asking me all these questions:

“Have you tried any other means of transport; private vehicle, ground ambulance? What was the patient’s response” “What?! No! This guy is having a heart attack!”

“I see and what is the ICD10 code for that, I think it maybe on the diagnosis list, ah yes I do see a few options, is this a NSTEMI, a STEMI, an otherSTEMI, or is the diagnosis still uncertain?” “Dude, he is having a STEMI, a big one, I already have acceptance with a cardiologist!”

“I see, well I will fax you the prior authorization form for cardiology referral in a moment, it appears as if your request for air transport has been approved, your approval number is ACS911, this authorization is good for 7 days, if you need to delay air transport past that time a new PA will need to be completed.”

“I told her it was not going to be an issue and hung up on her. Last I heard we were still waiting for the peer to peer on the cardiology referral. I hope it goes through, I mean they already cathed the guy and placed a stent.” Just then a phone call came in for Mr. Preshuns so I had to let him get back to more pressing matters in the ED. Though as I exited the back door I could not help but hear him growing upset with the interruption, “What do you mean you need more patient history to authorize cardiac rehab!?”