Pre-authorization is a tool for screening out requests for medical tests that are not necessary. It’s meant to avoid unwarranted costs, a necessary consideration in health care.

But the safety of the patient is another consideration, one of primary importance.

The current uproar over how the Hawaii Medical Service Association’s pre-authorization protocol affects patient care shines a light on how much work needs to be done to get the balance right.

This conflict must be resolved.

The issue involves complaints from doctors over the prolonged process for getting a green light for some patients’ medical tests, those that are deemed non-emergency. A story that appeared Wednesday by Star-Advertiser writer Kristen Consillio underscored the severe unhappiness with the system among some physicians.

The tension has been palpable. HMSA responded aggressively to the story, which was based largely on worrisome experiences related by Dr. Calvin Wong, chief of cardiology at the Queen’s Medical Center.

Attorney Paul Alston, representing HMSA, sent a chilling letter April 15, before the story was published, demanding that Wong retract his “false charges.”

This referred to the cardiologist’s discussion with the Star-Advertiser, including an episode involving patient Jerome Fukuhara, a Salt Lake resident. Fukuhara got his heart scan, which revealed major arterial blockages, from the emergency room after the initial request had been delayed in the pre-authorization process.

Wong’s concern about delay was entirely rational, and HMSA should not have clamped down on him.

In addition, lawmakers have responded to the controvery with House Bill 2740, in an effort to hold HMSA liable for repercussions of pre-authorization delays.

That proposal was ill-conceived: It’s implausible that the insurer could be found legally responsible for outcomes while recommended tests are pending.

But the bill’s introduction and hearing could push the insurer and its health care providers to the negotiating table, and that’s hopeful. Both sides must work out a system that’s less burdensome on the doctors.

HMSA, the state’s largest health insurer, has been dealing in recent weeks with protests over changes to its waiver policy. Those waivers had been issued to specific physicians, who had earned them based on good past practice of ordering tests based on medical need.

However, in January, the company changed that policy, rescinding its waivers in non-emergency cases.

HMSA executives said data showed the company’s cost-containment efforts have not worked, and that the company needed time to gather data on its providers and recalculate which ones merited a waiver.

What’s needed is for this research effort to conclude as quickly as possible, and a reasonable waiver program reinstituted.

The insurer has told doctors that if they believe the case is urgent, the standard pre-authorization review could be skipped. But in its place are still hurdles that can be onerous on a medical practice.

Deciding whether a test is necessary is now the role of a contractor: the Arizona-based company National Imaging Associates Inc., part of Magellan Health.

On its website, the company maintains that it employs board-certified physicians and decides 450,000 requests a month from doctors around the country.

But National’s pitch to potential clients also has a guarantee of “multi-year cost savings” for them. Clearly, the company’s interests lie in delivering on that cost-saving pledge.

That key interest does not align precisely with the interests of the physician or the patient, who must weigh economics against personal health risks.

HB 2740, in its preamble, issues that very call for a balanced approach: “The Legislature concludes that establishing basic standards for pre-authorization of medical treatment and services is appropriate, as it is in the best interest of the state to ensure that pre-authorization requirements do not negatively impact the health of Hawaii residents.”

Nobody should dispute that goal.

The medical profession is not blameless in the rising costs of care, and physicians do acknowledge that some tests are ordered inappropriately.

But also not acceptable is a review process that costs a practice an estimated $50 per patient, not to mention lost staff time.

Forcing doctors and their staff to jump through hoops excessively will only drive more of them to send patients to the emergency room, as happened to patient Fukuhara. And that adds to costs as well.

The goal of the current lawmaking session should be to press insurers and physicians to come to terms on a worrisome impediment to optimal health care for Hawaii’s residents.