Table 2.
Scheduling, referral and authorization: challenges and sample quotations
| A. Specialty clinics vary in acceptance of Medi-Cal insurance |
| “There’s certain days doctors are taking Medi-Cal and certain doctors that don’t, that they’re not contracted. And so we just had to schedule an appointment with the doctors that did take Medi-Cal.” (Administrator; Primary care) |
| “But then when we would call again, they will tell us the same thing that, you know, these doctors weren’t available for like three, four months. And so that’s not ideal for someone that needs to get in right now. So it was just a lot of back and forth… it took almost a month to try to figure out who was going to see this patient or not.” (Administrator; Adult primary care) |
| B. Authorization complexity leads to suboptimal and fragmented care |
| “I’m sure it would happen at least once a week, if not more…it is a very sad and frustrating thing to witness, having the patient check in just to find out when they run the insurance, that it is not cleared.” (Adult primary care administrator) |
| “But a lot of those things [surgeries] can be done in a week or two as an outpatient. Which, if you have insurance, great, you can get back in easily and get that done. But if you have Medi- Cal, it’s a lot more challenging.” (Surgical subspecialty nurse) |
| “She was seen by urgent care and there was concern for like retinal detachment, and so she had an appointment to be seen, and they were going to even potentially do a procedure and the referral hadn’t been processed….on our side, the [patient services representative] said that they kept reaching out and reaching out to [the health insurance organization], and they hadn’t heard back. And so, you know, this is something that I was really concerned that was gonna hold up her procedure for this retinal detachment that was so time sensitive.” (Adult primary care physician) |
| “[The patient] has to go make an appointment in their system to see the doctor and get the referral… they can’t get an appointment for six weeks… you know, all these Medi-Cal HMO systems are terrible. The wait times are terrible.” (Surgical specialty physician) |
| “Getting stuff done is challenging with Medi-Cal, in terms of if I want to order a PET scan or radiation. Everything just takes longer…they have complete access just like anybody else, it’s just everything’s more of a pain.” (Surgical specialty physician) |
| “I understand there’s going to be a one-month delay, because we have to fax things and wait to hear back from [the health insurance organization], Medi-Cal. But for cancer surgery, there should be a fast track. I mean, maybe there is and I’m not aware. But I have that anxiety about the cancer patients. And for that reason, I will do my best to get them taken care of inpatient.” (Surgical specialty physician) |
| “We can only see certain patients when they’re hospitalized, and then they can no longer follow up at [the academic medical center] as outpatient…that really fragmented not only their specialty care, but also their primary care.” (Adult primary care physician) |
| “I think he’s been in an emergency room, not always ours, probably three or four times in the past year with his problem. So I know he is able to access care when he is having a problem. So I don’t think it’s going to delay his care in any way that affects his clinical outcome.” (Surgical specialty physician) |
| C. Patients left confused by frequent Medi-Cal coverage changes and limited communication |
| “Medi-Cal HMO doesn’t make it easy for the patient… What it would even take to process a referral for an HMO patient…you can times that by, you know, ten, and it’s that level of difficulty to try to process something for a Medi-Cal HMO patient.”(Adult primary care administrator) |
| “So we try to handhold and try to guide them in the right door. But a lot of times that just falls through the cracks, and there’s nothing we can do.” (Adult primary care administrator) |
| “The vast majority [of patients] have a difficult time, even understanding how the healthcare system works in general […] I find we’re doing a lot of education on that.” (Adult primary care social worker) |
| “We scheduled the patient and then the financial clearance unit says, ‘Oh no! This patient’s Medi-Cal expired on such and such day. Now they have this [different MMC health insurance organization] that needs like an authorization. Okay, fine… call the patient [to advise them that] we were just informed that your Medi-Cal expired on such and such date.’ We then call the patient to ask: ‘Do you know what [insurance you now] have?’ The patient responds, ‘No, you know, I wasn’t aware of that.’ So, the patient gets upset, jumped through hoops to get back on their Medi-Cal… [the authorization process] just prolongs, just delays the patient from being seen.” (Surgical subspecialty administrator) |
Abbreviations: HMO, health maintenance organization; MMC, managed Medi-Cal; PCP, primary care physician