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The Administrative Roadblocks to Receiving Medical Care

By Miriam

I have faced so many administrative roadblocks when seeking medical care the last few
years. I am using the word administrative here to refer to anything that is not the clinical side.
These administrative aspects include scheduling appointments, making sure pre-authorizations
are approved, finding doctors whose panels are not full and who accept my insurance, making
sure referrals and orders are created and sent to the right place in a timely manner, and more.
Some of these tasks are done by clinical staff while others are handled by front desk staff, billing
departments, and more. It is the paperwork, scheduling, phone calls, and other tasks that have
to be done prior to being seen by a clinical staff member, getting imaging done, getting lab work
drawn, and other more clinical tasks. When the administrative side is delayed or I run into
roadblocks there, this leads to the clinical side getting delayed for weeks or months often. Many
of these roadblocks are preventable. For the ones that are not, we need to take steps to help
lessen them.

One administrative roadblock is getting the paperwork done that is sometimes required
in order for care to be provided. For example, a referral is sometimes required to see certain
specialists and orders are needed for lab work and imaging. I rarely can simply walk in or
schedule an appointment to receive care without orders and referrals being created first,
especially if I want my health insurance to pay for that care. On multiple occasions, doctors
have told me I needed certain care only for them to not put in the referral or order right away.
There have been multiple reasons for delays in receiving those referrals and orders.
Sometimes, a specialist thinks I need certain imaging done, though that type of imaging falls
outside of their specialty and they want either another specialist or primary care to order it
instead of ordering it themselves. Then, there is a delay in getting that imaging done while I try
to get in contact with another doctor who is willing to order it. In the meantime, I know I need
that care and am simply waiting on the paperwork. I also once had a specialist say they would
refer me to a different type of specialist they thought I should see, but it took me following up
with them for weeks before that specialist actually created the referral itself. Other times, there
have been errors in orders that needed correcting before I could schedule. For example, I once
had a doctor say they were going to order an MRI of my neck, but when I went to schedule with
radiology, I was informed an MRI of the head was sent over. I then had to reach back out to the
doctor who ordered it and have the correct order sent over. There have also been times where I
was told to repeat certain lab work or imaging in a year or a few months due to abnormal
findings on the initial lab work or imaging needing to be checked again in the future, but the
doctor who ordered it the first time had changed practices or otherwise was inaccessible when it
came time to re-do it. I then had to find another doctor to put in the order. Not having access to
the same doctor when it comes time to do follow up testing has led to blood tests and imaging
being delayed for months past when that original doctor planned to re-order them. I had another
time where the primary care practice I was currently in said they could not order a certain type of
imaging multiple doctors thought I needed and gave me a referral for a specialist they thought
could. Then, I was unable to schedule with that specialist. A nurse who works for that specialist
told me that specialist only deals with already diagnosed patients or findings on imaging that
was already done. The nurse insisted primary care should order the imaging, even though my primary care doctor already told me they could not and had referred me to that specialist in
order to have them order it. It was certainly a dead end to then have that specialist say they do
not order imaging and I had to find another way past it on my own. At that point, I was getting
pinballed between different doctors, as I tend to call it. Simply bounced around between
departments, with no one taking responsibility and no clear final destination for getting this taken
care of. I ended up switching to a new primary care practice over this and other issues, but it
took over a month to do so due to further administrative issues.

One of the administrative issues that makes it hard to switch primary care practices is
many doctors within local practices have full panels. This means they have too many patients
currently to take new ones. Even when I am able to get on a doctor’s panel, I have had times
where that practice later builds up an overwhelming number of patients and does not have open
appointments for months at a time, if at all. Multiple times in different practices, I have not been
able to get a sick visit for weeks while follow up visits were not available for months. This
includes times where it was absolutely crucial I see primary care without weeks long delays,
such as when an emergency room instructed me to see primary care within a few days to
ensure an antibiotic was working to clear an infection and another time where I had been very
sick from a virus (not sick enough for the ER) and needed primary care to clear me to return to
school after the virus had been severe enough to miss class.

Primary care is not the only one who has been booked up for months lately. Multiple
specialists I have been referred to have been booked up for months as well. One was booked
up for seven months from when I called. I requested to be put on their waitlist in case a sooner
appointment opened only for them to call me a few weeks later to say they needed to
reschedule my appointment for even further out than before. Other times, I was able to get a
sooner appointment as a result of being placed on a waitlist. However, I typically have had to
wait at least two or three months between when I schedule and when the first open appointment
is for specialists across multiple departments lately. These delays are not simply inconvenient.
More than once, delays in care have worsened my health. For example, the infection I
mentioned earlier might not have happened if I had gotten in to see a podiatrist or primary care
sooner. It started off as an injury to my toe that did not grow back right, leading to an ingrown
toenail. Both primary care and a local podiatrist I called were booked up for weeks and the skin
next to the toenail got infected in the time between first seeking care and finally getting the
ingrown toenail treated. That is not the only time my health has worsened while waiting for
appointments. Being seen finally does not always solve or prevent the health issue, though
imagine not being seen at all simply due to administrative issues while my health worsens, with
the possibility that receiving care could have improved it. There have been times where finally
receiving care did improve my health, such as when it took months to get a certain diagnostic
procedure after a new physical health issue emerged. That procedure was able to diagnose the
issue and led to an effective treatment being prescribed the same day as the procedure. In the
meantime, that health issue did not go away on its own as I waited months to receive care.
When administrative issues block or delay my care, I am often left on my own trying to use
self-advocacy to get around those roadblocks and doing as much self-care as possible in the
meantime. However, self-care only goes so far when you are dealing with real clinical issues
and physical health changes doctors have acknowledged, but for which care is being delayed
by administrative issues.

With scheduling, another administrative issue I have run into is doctors not having their
calendars open yet for an upcoming month. Instead of their practice placing me on a waitlist or
calling me once the schedule opens, I am told to call back myself. Sometimes, I call back after
waiting the amount of time the front desk staff told me it would take for the calendar to open only
for that doctor to be booked up already. How am I supposed to be seen if when I try to schedule,
I am first told it is impossible to schedule yet due to the doctor’s calendar not being open, but
then, they book up extremely fast once the calendar is open before I am able to get an open
spot? I have even had this occur within an office where other doctors in the practice had their
calendars open for further out, but were booked up already. So some doctors within the same
practice are booked up while others simply do not let you schedule with them for a particular
month yet, even at times when that calendar month is only a month or two away. I feel like this
issue could be prevented simply by adjusting how scheduling is conducted, such as creating a
waitlist or call back system for patients that are known to need a follow up visit at a certain point
in time and have not been scheduled yet.

There have also been administrative issues that only came to light after the appointment
was scheduled. For example, I have run into issues more than once now with pre-authorization
requests failing to be started after I scheduled imaging. Basically, a pre-authorization is when it
is required by health insurance organizations to have orders for imaging be reviewed and
approved before it takes place, though the request for pre-authorization is put in after
scheduling. Previously, pre-authorization requests went through without me getting involved.
Lately, I have had multiple times where I reached the point of finally seeing the appropriate
doctor, getting the order completed, and the appointment scheduled only for the
pre-authorization request to not be put in, let alone approved. For one set of imaging, the order
had been created and appointment scheduled weeks prior to the appointment, due to the
radiology department being booked up for a few weeks. However, the pre-authorization request
was not sent until two days before the appointment and then got stuck in review. I spent hours
the day before calling radiology, my insurance, and the department of the doctor who ordered
the imaging to get the pre-authorization approved. Each party kept saying they were not hearing
back from the other. After following up with them repeatedly throughout the day, I eventually got
it approved the day before the appointment. If I had not fought to get it approved, I would have
been forced to reschedule an appointment that was already delayed for weeks due to a lack of
open appointments. Unfortunately, after all that work, my chart was not properly updated. So
when I arrived for my appointment, I was told by the front desk staff at check-in that my chart
still showed the pre-authorization stuck in review and that I could not get the imaging done. I
politely and professionally pushed back, insisting they call the person in the pre-certification
department who had finally gotten it approved. The front desk would not call them at first, and
instead made me call them and ask that they speak to each other. Eventually, the two staff
spoke to each other and got the situation straightened out. I was able to get the imaging done
after all, but I was not able to check in while they straightened this out. I just sat in the waiting
room for about an hour until it was resolved, hoping the imaging would get done. Keep in mind
this was not routine imaging or preventative care. At the time, I was significantly unwell with
specific symptoms multiple clinical team members had agreed the imaging could help diagnose.
Imagine having a significant, mysterious physical health issue that doctors have specific steps
they want to take to hopefully diagnose, but you come very close to not receiving care at all due
to administrative issues where different departments and organizations are failing to
communicate with each other in time to not have to reschedule. The only reason I did not have
to reschedule was by doing hours and hours of self-advocacy and not giving up on my end. If
the pre-authorization had not been put in at the last minute and if the departments had simply
talked to each other instead of me having to make countless phone calls to mediate for them, it
would have saved me a lot of stress and ensured my care was not delayed. I only found out
about the pre-authorization issue prior to showing up for the appointment because someone
called me two days prior saying I might have to reschedule if it was not approved in time, which
led to me scrambling to take care of it myself the day before the appointment. The next time I
had imaging scheduled, I called four business days in advance of the appointment to check on
the status of the pre-authorization request and found out it had not been sent yet. I spent that
day and the following one calling around trying to get the pre-authorization sent and approved,
scrambling to get it fixed and reaching roadblocks along the way, just like the time before that.
Except that second time, I proactively initiated those calls a few days further in advance to
hopefully prevent a last minute scramble. The path it took to get the pre-authorizations
completed each time was not exactly the same. Different smaller issues popped up along the
way each time, such as a person I was supposed to call back not having their voicemail set up,
numbers having changed in the time between each incident, and different organizations
referring to the same test by different names. These smaller issues led to further communication
issues. Unfortunately, there have been repeated problems in regards to communication between
parties involved and with processing the pre-authorizations in a timely manner. This is more
administrative than clinical and an obstacle to getting the clinical care I need, which in this case
is actually getting the imaging done. Many of the medical professionals I speak to keep
sympathetically saying that a patient should not have to do this much work themselves to get
this done, yet I am practically being forced to in order to receive care.

This is not all the administrative issues I have faced when seeking medical care. I could
probably fill a whole book more vividly describing my experiences and listing out more issues
than I mentioned here. More examples would only further the point that there are many barriers
to receiving medical care that have little to nothing to do with the clinical side. Often, I am
waiting weeks or months at a time to get the care that medical professionals acknowledge I
need. This is not about me simply thinking I need certain care. This is doctors suggesting next
steps only to be blocked by administrative issues when seeking those clinical next steps. It is
trying to follow a doctor’s advice only to run into administrative delays. This does not even
include the additional issues that sometimes occur on the clinical side, just the barriers to
reaching the clinical side at all.

Some of these issues come down to staffing shortages, as medical staff often remind me
of when I speak to them. There needs to be more staff on both the clinical and administrative
side in order to handle the paperwork and see patients sooner. Solving the staffing shortages is
a complex issue involving making sure enough people are trained, that there is enough money
available to hire more staff, etc. However, some of these issues are less directly related to the
number of staff. Some of the administrative errors could possibly be solved through changes in
the software used. There could be a notification system created to better track when
pre-authorization requests have not been sent yet. Even better, it could prioritize the unsent
ones by which appointment is soonest. There could be more data validation steps added to the
software or processes used to make sure orders are entered correctly. There might be software
improvements that could be made in regards to waitlists for appointments and to the scheduling
process. For example, recently I was told my primary care was booked up. However, the
scheduler was automatically only searching the schedule for certain doctors to try to match me
to doctors in the practice I had seen previously. When I insisted I did not mind seeing a new
doctor and the priority at that point was getting seen as soon as possible, the scheduler was
able to find me an appointment for the next day when looking more widely at the different
doctors in the practice! While there are benefits to following up with the same doctors, it is not
realistic at this point when those doctors keep being booked up for months at a time and I keep
seeing a different doctor each time I am there anyway. The doctor I ended up seeing was
extremely good and helped move my care along in multiple ways within that one visit. If I had
not insisted the scheduler check other doctors’ availability, I would have had to wait months for
an appointment again instead of being seen the next day. In this regard, either the process the
schedulers use to check for appointments or the software used could be improved to help
patients get in sooner like that and make sure open appointments are not overlooked. There
have also been times where I was able to get a sooner appointment by calling again in a few
days or weeks after scheduling. This happened even when I was already on a waitlist and
should have been called by the practice if an appointment opened up sooner instead of only
finding out by calling myself. Another time, the waitlist software automatically offered an
appointment to me in another state that was about a hundred miles away instead of only filtering
for locations close to me (that specialty had multiple locations). Both these examples show the
software used for the waitlist could be improved to make sure patients are getting the earliest
appointment at an appropriate location. I am only making educated guesses here on what
specifically needs to be improved. To really solve these issues, there needs to be data analysis
and studies of the processes used for these administrative tasks in order to make informed
decisions on how to improve these issues based on what is actually happening behind the
scenes, beyond what I am aware of from the patient side. There is plenty of data already
available in regards to this, such as patient surveys medical practices already conduct. There
are also opportunities for further data collection to analyze this situation going forward, such as
creating new surveys and studies that specifically focus on the administrative side, as long as
those higher up in these organizations choose to invest in exploring the causes of these issues
and taking action to solve them. There may be legal or budgetary obstacles when addressing
such large issues within healthcare, but they are worth addressing to improve patient health,
relieve stress felt by both staff and patients in the face of some of these preventable problems,
and lessen any added expenses these problems may lead to when they are corrected on an
individual basis instead of being addressed in a way that would prevent it from happening again.