what does prior authorization mean? (3rd party insurance issues)

[ooscubaoo]

Can someone explain what a prior Authorization means when you process the rx through the insurance? what steps do we take to solve this insurance problem? why does the prior authorization appear?


how do you describe to the patient what the situation is?

also what other type of insurance problems do you guys encounter in a pharmacy?

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[museabuse]

Can someone explain what a prior Authorization means when you process the rx through the insurance? what steps do we take to solve this insurance problem? why does the prior authorization appear?


how do you describe to the patient what the situation is?

also what other type of insurance problems do you guys encounter in a pharmacy?

Prior auth means the insurance company does not want to pay unless the doctor fills out some forms and sends it to the insurance company.

I look at it like a rebate... a lot of people buy something and never use the rebate, because they forget or it is a hassle to send it in.

The insurance makes it difficult for the medication to be covered in hopes that the patient will forget about it or get it switched to something cheaper. It's all about making money.

This is what I say to customer when a medication is denied due to prior auth. "I am sorry but the insurance company is requiring a prior auth. That means we have to contact the doctor so he can fill out forms for the insurance to determine that you need to be on this medication. The docotor may also switch the medication. If the doctor wants to do the prior auth it can take several days. We will fax the doctor now and wait to hear back from them. Call the doctor if you feel the process needs to addressed sooner. Thanks you and have a great day "

Other insurance problems...
old insurance card, new insurance card, wrong ID #, insurance has wrong DOB, no insurance, vactaion override, and have not gotten mail order. Also DUR related, day supply, drug interations, too soon.

 

[vafcarrot]

PA poops up that last five minutes you are filling orders and is due to the fact that you have not pulled out enough hair that day. At my place of work, you say a silent apology to the billing people, print the scripts anyway and pray that by then end of the month they won't be able to figure out you're the one that filled it without getting in paid for.

Can I just say that I am SOOOOO grateful that my work had a billing department with four guys whose complete and utter job is to deal with crap like this?

 

[ooscubaoo]

Other insurance problems...
old insurance card, new insurance card, wrong ID #, insurance has wrong DOB, no insurance, vactaion override, and have not gotten mail order. Also DUR related, day supply, drug interations, too soon.

CAn you explain what DUR Claim rejects mean such as day supply and drug interaction? what do you do if you are faced with those messages?

 

[off2skl]

CAn you explain what DUR Claim rejects mean such as day supply and drug interaction? what do you do if you are faced with those messages?

The claim reject on day supply referes to the fact that the insurance company will only cover a 30 day supply at a time. The way to deal with this is to either change the quantity dispensed to give a 30 day supply or, if it is an item whose quantity cannot be changed (inhalers, insulin, eye drops come to mind) then you comment in the computer what the actual day supply is and "cannot break package." Or something to that effect (that's what we do)

Drug interactions depends on the level of interaction. Some are minor (level 1 is what comes up on my screen). Others need a pharmacist to review and still then sometimes we need to call the insurance company to get a code to override the DUR.

There are other rejects like refill too soon, and for products that are not covered on the formulary. Sometimes it comes up when a plan prefers the patient to use their mail order service too.

 

[WVUPharm2007]

what do you do if you are faced with those messages?

I generally try putting in a random set of numbers/letters into the DUR reject boxes until the insurance gods are pleased with my offering. When that fails I sacrifice a cow and place it over the keyboard hoping that will please the insurance gods...it hasn't yet, interestingly.

 

[baggywrinkle]

I generally try putting in a random set of numbers/letters into the DUR reject boxes until the insurance gods are pleased with my offering. When that fails I sacrifice a cow and place it over the keyboard hoping that will please the insurance gods...it hasn't yet, interestingly.

Careful with that. During an audit it may qualify as insurance fraud which may result in prison time as long as 10 years and fines of 200,000 dollars. Not for you, the technician, but your pharmacist of record on the prescription.

There is a special federal database of those individuals who have been busted for medicaid fraud who can basically never work again because of it.
No one will hire them.

 

[WVUPharm2007]

I don't do it with anything that is an actual problem. I'm not going to push through a lortab that's 25 days too soon.

 

[baggywrinkle]

CAn you explain what DUR Claim rejects mean such as day supply and drug interaction? what do you do if you are faced with those messages?

Just the insurance companies practicing medicine. Their medical advisory board sets up standards of care which are hard coded into the computer as drug utilization review warning flags. Step therapy is a good example. Why use the expensive COX2 inhibitor when an older cheaper NSAI can do the job. The computer flags require the physician to file for prior authorization documenting treatment failure with one or more of the older drugs before payment for the expensive drug is granted. Another example is duration of therapy as opposed to days supply. Ambien or Protonix were never intended to be used forever and ever the way you see them prescribed. The FDA indications are for short term use only. The computer can and will flag this.

This can improve patient care by pulling on the purse strings prodding physicians to toe the standard of care line.

The DUR system is also abused IMHO by cost conscious insurance companies who are all too willing to place a price tag on life. How often have you seen a DUR flag for a non-preferred drug? Insurance companies set up formularies with a drug selected as the preferred candidate from a given class. When Prilosec went OTC medicaid made it the preferred drug with most insurance companies soon jumping on the band wagon. This is fine for most patients, however I encountered many who failed Prilosec but did well with Nexium or Protonix. Some of the cheesier insurance companies make it a shell game. I have spoken to customers who went through the prior authorization hell to get Prevacid changed to Nexium in one fiscal quarter only to have the preferred drug change BACK to Prevacid after the next negotiation period. This does not serve quality of care because these drugs are not necessarily plug-n-play for individual patients as the formulary boards would have you believe. Don't let em kid you, it is all about the money. If they can irritate you enough with the prior authorization game maybe you will give up and just go away fattening their bottom line.

 

[ooscubaoo]

when the pharmacy fills out a Cal Optima CPAS form online because the drug is not on the formulary, is that considered a prior authorization?