Prior Authorizations are totally out of control
I’ve posted this video before, but it needs repeating.
Today, our doctor spent an hour trying to get a CT approved and failed. Then we tried to get someone a refill of their Advair so they could breathe… It turns out the secret answer was Symbicort, which only took a half hour to figure out. Why make it so hard?
For some reason, we are again seeing Levothyroxine tablets being denied for Prior Authorization. I don’t understand!!!!
Lots of thoughts here, as a former Family Practitioner (retired) and a Medical Director for multiple insurers, doings lots of prior auth decisions, and participating in creation of Formularies.
Be wary of the contract you sign when you accept an insurer. You agree to use their formulary (thus creating the responsibility on YOU to keep up with the changes which means reading their updates) for their members. You are responsible for keeping up with their requirements. It’s a semi-hidden additional cost of accepting their reimbursement rates, and the increased cost to you of keeping up with their requirements. I tried to hire someone to keep and update a multi-insurer database of PA requirements and formulary, but they basically told me it was near impossible too expensive. Some EHR’s do it. Some software apps programs out there do it as well. But that means using an external application.
PA requirements for CT scans also vary by insurer – by signing a contract with that insurer, you agree to follow their requirements (see prior paragraph).
In practice, I dropped an entire insurance company (I had six members) because they created a new rule that I “Had to” draw their member’s labs AND send them to a lab I did not use. That meant devoting a section of my tiny lab draw station for this new lab for their six members OR using equipment at my own expense, or stealing supplies from one of two other labs. After attempting to negotiate and failing, I gave them notice of termination and notified the patients we could not see them because of their insurance requirements.
In practice, when we needed prior auth by phone, and knew most of the time was going to be spent on hold waiting for the next person to pick up or transfer us, we had the patient/member do all the holding, and when a live person got on the line, one of my staff would respond. Suddenly the patients would either change insurance of do the work for us of waiting.
Before signing and accepting an insurer, make sure their rates reflect the extra work hidden in the “You agree to,” language. Sometimes, it is NOT worth accepting an insurer, or make sure their rates for you (and yes, they are potentially malleable) reflect the additional work.
If you work for a someone else and do not make those decisions, you are basically working for free if your employer does not make that information available.
I could go on for days…
Fair enough to watch out for these clauses when you sign on for an insurance plan. But how to deal with the inevitable unilateral changing rules? When your favorite lab “A” was OK when you signed on to the plan, then a few months later, you are required to draw the labs and send to lab “B” as you described?
“the secret answer was Symbicort”
A new version of Groucho’s “You Bet Your Life” – and the title is more appropriate than ever.
I was one of those people at the insurance company. I had to quit due to my morals!
No longer deal with this nonsense. Send the following message to all patients who request a prior authorization for anything “I decline to submit to the tyranny of all health insurers requiring prior authorizations for more and more medications. Have suffered enough aggravation and wasted time and shall not tolerate it anymore. Suggest you download an App called GoodRx into your smartphone and price the cash price at local pharmacies, let me know which one you prefer and shall send future refills there.”
The problem is the patient, who is already paying a ton of money for drug coverage and health insurance coverage, is left high and dry if the doctor refuses. GoodRx only works in limited circumstances. The price of generic Advair is still over $100 a month with GoodRx. If the drug is not available generically, GoodRx is a waste of effort.
Ironically, that same insurance company will later send you a notice criticizing your pulmonary care because you don’t have any maintenance therapy and are only prescribing Albuterol.
The work around for a CT scan is to send the patient to the ER, saying they are in deep distress. Usually, that will do the trick. Now insurance has a $15,000 bill they have to pay instead of a $300 bill. Unfortunately, the same technique does not work for MRI scans.
I agree with Frank. The patient has no right to make this your problem, particularly when you are not compensated for the cost of gaining prior authorization.
That is, of course, the plan. Make every failure of the system the doctor’s responsibility.