Prior authorization for child and adolescent psychiatric patients deemed to be in need of inpatient psychiatric admission

Four million children and adolescents in the US suffer from a serious mental disorder that causes significant functional impairments at home, at school and with peers. In youth, many of these disorders can have life-long deleterious effects.

Although obtaining timely care for young people with psychiatric disorders is vitally important, insurers make obtaining needed care difficult, by requiring prior authorizations before patients are admitted.

We sought to formally examine this process as it pertains to children and adolescents are deemed in need of inpatient admission.

To do so, between the periods of May 2014 and October 2014, licensed social workers employed in the psychiatric consultation service embedded in the emergency room at Hasbro Children’s Hospital in Rhode Island, completed paperwork each time they contacted an insurance company on behalf of a child deemed in need of psychiatric admission.

We obtained 203 data sheets, and of these individuals, 55.7% (113/207) were female and 44.3% (90/203) were male.  They ranged in age from 4 to 19 years old; the average age was 13.6.  The most common reasons for admission included suicidal ideation or a suicide attempt (114 patients, or 56.2%), aggression (44 patients, or 21.7%), and homicidal ideation (21 patients, or 10.4%).

The average time required to obtain authorization from the insurance company from the time of first contact to authorization was 59.8 minutes ranging from 3 minutes to 270 minutes. There were variations in time required based on insurance type: Blue Cross required 76.5 minutes on average to complete the authorization process.  United Health Care required 56 minutes on average and Neighborhood Health Plan required 51.4 minutes.  The average length of stay authorized was 2.42 days, which included some patients boarding overnight in the medical hospital before a psychiatric bed was available. All 203 requests for authorization were granted and none were denied.

Given that 100% of our attempts to obtain authorization were granted, the need to obtain prior authorizations appears to function more as an administrative hurdle rather than an effective triage to deny care, because if professionals know they or their colleagues are going to have to spend lengthy amounts of time on the phone with the insurance company, they may think twice prior to trying to admit a given patient.

The requirement to obtain prior authorization is common across the country. One national survey of the time that physicians and other practice administrators spend interacting with insurance companies calculated that the annual cost to our health care system for all physicians nationwide to engage in these non-reimbursable interactions was approximately $31 billion.  If physicians and social workers doing psychiatric consultations in the emergency room are spending significant amounts of time obtaining authorization rather than seeing patients, the costs could also be astoundingly high.

Insurance reviews and pre-authorization requests are just a part of what makes accessing needed psychiatric care difficult, given that finding comprehensive services for children and adolescents is only possible in certain parts of the country. Adding prior authorization to an already difficult process, especially for psychiatric patients who are deemed to be of “imminent risk” to themselves or others, seems both dangerous and predatory.

Onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted. It burdens our psychiatric clinicians and functions to limit care by placing time consuming bureaucratic burdens on clinicians rather than meaningfully evaluating patient’s needs.  Insurance companies need to stop requiring prior authorizations so that our patients receive the safest and most timely care possible.

J. Wesley Boyd
Center for Bioethics, Harvard Medical School, 26 Central Street, Somerville, MA, USA
Department of Psychiatry, Cambridge Health Alliance/Harvard Medical School, Somerville, MA, USA



Prior authorization for child and adolescent psychiatric patients deemed to be in need of inpatient admission.
Funkenstein A, Hartselle S, Boyd JW.
Am J Emerg Med. 2016 Feb 12


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