Alice in Pre-Cert Land
The wild and wacky world of drug pre-certification has become downright surreal of late.
Case 1:
Patient who has tried three of the four available nasal steroid sprays with inadequate response to each. I suggest trying the last one (which happens, in my personal perennially allergic opinion to be the most efficacious) and write the prescription. Not unexpectedly, I get a request for a prior authorization. I get the first sense of foreboding upon perusing the form: there is one -- and only one -- question:
Has the patient had an adverse reaction to [the preferred medications]?Well, no, but they didn't work. I write this extra information in around the single question on the sheet and fax it back. Surprise (not): the only acceptable criteria for coverage of the requested medication is an adverse reaction to the preferred ones.
What they're saying is that they will only cover medications that don't work for this patient.
That was the red pill. Ready for the blue one?
Case 2:
I see a patient who, I fear, has a peptic ulcer. I prescribe generic omeprazole 40 mg. (I am aware this is available over the counter, but in the quantities he needs it can get pricey. He pays for prescription coverage, so I figure I'll try writing it for him. And don't go telling me I should just write for Nexium. The response is the same for any PPI.) I receive a phone call from the pharmacy that the medication requires prior authorization, despite the fact that it's a generic. My staffer spends an outrageous amount of time on the phone being told she needs to call no fewer than three different 1-800 numbers. The final verdict:
The prescription will only be covered if the patient fails the OTC version.Okay, let me see if I've got this straight: they will pay for the prescription, but only if it doesn't work.
I'm sorry, but "WTF" just seems so inadequate. My mind hurts trying to twist its way around this nonsense. I need drugs. No, wait: they'll probably need pre-certification. I'll just have to settle for alcohol.
posted by #1 Dinosaur @ 5:22 AM
11 comments
11 Comments:
Perhaps a consequence of the fact that a preponderance of insurance company leaders have a legal background rather than an operations or clinical one. The rules are theirs, customers be damned, a la William Vanderbilt. If you like these, then you'll love the ones comming when the 'new' health initiatives kick in.
Chuck Brooks
FutureWare SCG
Same headache for me. I have a 600+ lb. patient. Can't use Metformin due to creatinine >1.3, don't care to use TZD due to her venous stasis ulcers on her legs. She has sugars consistantly >300 on Lantus insulin 100 units a day.
I want to add Symlin to help the insulin AND reduce her appetite. Despite my documentation that she has sugars >300 they want an A1c!!!!!!!!!!!!!!!!!
I think the whole PA thing is solely to put just one more hoop in front of us, hoping we won't jump through it and they won't have to pay. I've NEVER had one denied once I call--it's just that it's a huge pain in the ass to take the time to do it and the evil powers that be know that and are banking on a lot of us not doing it.
I have to agree with HugeMD! Coming from a pharmacy perspective, prior authorizations are the biggest burden of time on both us and the MD's. Be ready for a lot more of them, too. Medicare patients who got their 3 month supplies in December will be refilling for the first time this year, and a lot of things that were previously covered seem to not be covered anymore, without of course a prior authorization. I have to give kudos to you that you actually take care of this evil but necessary paper work; I've had doctors take up to 2 months (with us pestering them constantly) before even attempting it, and I've had doctors tell me they just don't do them at all (which I also think is ridiculous).
My suspicion is that insurance companies are run on the Wernher von Braun plan (as described by Tom Lehrer):
" 'Once the rockets are up, who cares where they come down
That's not my department,' says Wernher von Braun."
Pre-authorization is just simply covert rationing - rationing by inconvenience. If you're persistent and scream loud enough at the medical director or someone like that, everything eventually gets approved. Problem is that they know that 98% will quit before they get that far and just accept the denials. That's the way it's always been, and we keep playing along. When I was a kid I would say "I don't like the way you play, and I'm not playing with you anymore." Why not now?
I've gotten to the point where I don't even get my generics covered by my health ins anymore. In more cases than not, Costco's generic prices for a 90 day supply are cheaper than my copay and I don't have to worry about getting the ins co to approve.
And the beauty is that anyone, not just members, can use the Costco pharmacy. Thought some of your patients might be able to utilize this info given your proximity to one.
What they're saying is that they will only cover medications that don't work for this patient.
What a steaming pile of llama droppings. We'd be a whole lot better off if the insurance companies let docs make the medical decisions. God, but I'm sick of power hungry swamp donkeys whose sole raiason d'etre is to control us little people.
I can identify with all these comments. I often walk through my office after the last patient has been seen and see every nurse and receltionist on the phone: NOT engaged in important patient care, but on hold trying to get PAs.
And this is another area (among many) where our professional organization has been COMPLETELY worthless. They are so intimidated by the insurance companies that they absolutely refuse to stand up for their physician members. We can only blame ourselves.
It's simple math, really. Hold up every prescription for one week, and the pharmacy benefit company makes 2% more profit on the year.
Anonymous is right. Our professional organizations are completly worthless in this area. Mine is too busy trying to promote a variety of airy-fairy stuff (medical home, indeed, what do they think I've been doing for the last 30 years) to be any use at all. And think, dear professional readers, of the dues we pay these organizations....what for?
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