Charging patients for PA in insurance practice

[liquidshadow22]

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Do most insurance plans prohibit chargining for prior authorization if you are in network?

 

[Jules A]

I don't know but I wish I could muster the courage to charge my out of network patients for PAs...the price would be $500 each.

 

[filmfan10]

Rheum here.

I do not charge for Prior authorization forms.

I know of a psychiatrist in the area. That psychiatrist charges prior authorization, per page. I think he charges a low dollar amount per page.

I don't know about charging for prior authorizations. I feel that we would get a lot of pushback from my patients.

I have patients that refuse to pay $4 for a 30 day supply of medications through goodrx.

So, I am not sure if patients would be willing to go along with charges for prior authorizations

 

[littlefred]

Rheum here.

I do not charge for Prior authorization forms.

I know of a psychiatrist in the area. That psychiatrist charges prior authorization, per page. I think he charges a low dollar amount per page.

I don't know about charging for prior authorizations. I feel that we would get a lot of pushback from my patients.

I have patients that refuse to pay $4 for a 30 day supply of medications through goodrx.

So, I am not sure if patients would be willing to go along with charges for prior authorizations

They might be compelled to do so if it's scheduled by the DEA.

 

[allantois]

I don't think private insurances can prohibit this. My PCP office charges a convenience fee for lab on-site and the one before charged a convenience fee for evening or weekend appointments. I know of offices that charge for PAs. I don't charge for PAs since I usually know that I am prescribing meds that require a PA (it's mostly Vyvanse for me). Unfortunately, with some insurances it's a massive time sink for the staff (luckily I don't do these PAs). Sometimes it's easier for patients to go through GoodRx if it's something like Pristiq or Ramelteon that they are wanting a PA on

 

[liquidshadow22]

The PAs are absolutely bonkers these days. I've seen fluoxetine, forms of adderall, Ritalin, Vyvanse, Strattera, daytrana match, Abilify, latuda, vraylar. It's a pain in the butt.


The insurances make it so difficult just to write a prescription then I am reading that some actually can prohibit charging the patient. My guess is it is state and insurance dependent. Need a good Healthcare attorney. Sigh.

Wish AMA could litigate the **** out of the insurance companies to get eradicate these malignant PAs

 

[HemeOncHopeful19]

I know my local doc does not charge for the initial PA but will charge for any denial appeal or peer to peer.

 

[calvnandhobbs68]

Yeah most private insurances don’t really prohibit you for providing services that aren’t covered by the insurance contract, so it’s not that unusual to charge for external paperwork. I don’t for PAs personally as I typically just try to stay away from meds that I know will require PAs. I mean here’s the thing it’s not really the patients fault the med requires a PA, unless the patient is specifically requesting that med over another one….so like why would I make a bipolar patient pay for the fact their insurance company is being a dick and making me do a PA for Latuda when they couldn’t tolerate lamictal and don’t want to gain a bunch of weight on seroquel.

I have heard of people basically scheduling an appointment and having the patient sit there with them if they have to appeal a PA both to show the patient what you have to go through (so they appreciate it a bit more) and so you can tell whoever the reviewer is that you have the patient there with you to listen in on why they’re denying the medication. Bet that makes 99% of reviewers roll over pretty fast. Pretty smart move imo and then you get paid for an appointment lol.

Most branded meds will require PAs. So not weird to me about the PAs for Vyvanse, Latuda, Vraylar. Generic atomoxetine has been a weird one for me though too.

 

[liquidshadow22]

I hear you but also I'm not sure how you properly code for a visit like that. Some also do that for disability paperwork but there's really no medical care going on.

The reality is I have zero interest in doing a PA. I'd rather hire staff to do it but that costs money and I prefer to pass that cost onto the patient for small fee for a successful PA which still in the end saves the patirnt money

 

[allantois]

I hear you but also I'm not sure how you properly code for a visit like that. Some also do that for disability paperwork but there's really no medical care going on.

The reality is I have zero interest in doing a PA. I'd rather hire staff to do it but that costs money and I prefer to pass that cost onto the patient for small fee for a successful PA which still in the end saves the patirnt money

Have you done PAs?

Over time you kind of know which insurances cover what (the reps can often advise you of this). You can try charging for whatever you want. You can get pushback from patients.

 

[Ironspy]

I charge my regular hourly fee for PAs prorated to the next 10 minutes and they have to prepay for 30 min to get the process started. This is spelled out in detail in my intake paperwork. I’ve had minimal push back but I am sure that some patients have voted with their feet and decided not to see me for intake which is fine. Most meds can go through goodrx for cheaper than me doing a PA.

 

[Merovinge]

Generic atomoxetine has been a weird one for me though too.

F this absolute garbage. Have been having problems with this med again too which is preposterous as it costs the insurance company less than psychostimulant I was taking them off of. This system is such complete nonsense that I don't even know where to begin with my rage.

 

[calvnandhobbs68]

I hear you but also I'm not sure how you properly code for a visit like that. Some also do that for disability paperwork but there's really no medical care going on.

The reality is I have zero interest in doing a PA. I'd rather hire staff to do it but that costs money and I prefer to pass that cost onto the patient for small fee for a successful PA which still in the end saves the patirnt money

You just bill an EM code based on time. Ask the patient how they’re doing, how are their meds going, oh still not working well in order to aid in me properly providing medical care we need to call your insurance company to get this medication you need for your condition covered!

Look at the rules for time spent for EM now. They’re pretty all inclusive of any time spent providing any sort of service related to that patients care the day of service.

 

[allantois]

I wonder if they (insurance) realize how much they are overpaying for visits for having patients jump through the hoops of getting their meds approved

 

[calvnandhobbs68]

I wonder if they (insurance) realize how much they are overpaying for visits for having patients jump through the hoops of getting their meds approved

Nah they aren't, it's still cost savings for them overall. There are plenty of doctors who just either then don't prescribe the medication or prescribe something cheaper when they get the PA request.

Say it costs 30 bucks a month for Adderall XR, which is about the average where I am. Say it costs about 380-400 bucks a month for Vyvanse (just guesstimate based off GoodRx pricing although I'm sure some insurance companies have their own deals with the manufacturers). That's $4200/year cost difference. Divide that by the average cost of a 99214 in your area to figure out how many doctors theyd have to get charging them a patient visit to do the PA and you can figure out how that cost works out favorably from their end (plus not many doctors even do this...they just have their office staff or secretary try to put PAs through usually).

 

[PsyDr]

Some also do that for disability paperwork but there's really no medical care going on.

Uhhh, there is a CPT code for that, and the AMA has a position statement that contradicts your opinion.

 

[clausewitz2]

I am fairly strict in charging my paperwork completion fee in my private practice (my hourly rate pro-rated in 15 minute intervals) but it honestly never occurred to me to charge for prior authorizations. Like @calvnandhobbs68 I don't run into many prior authorizations I need to do for my main payors, apart from OCD-dosed SSRIs which I have commented on elsewhere and which I now simply refuse to attempt as they are almost always denied and pretty cheap out of pocket. My biggest PITA from PAs is some of my cash pay patients who are happy paying cash to see me because they have cut-rate health insurance that wants to see medical necessity demonstrated for almost everything before they'll pay.

At the end of the day charging for PAs would be tricky; I can't always predict what meds will trigger one for which people and I don't like the idea of patients getting surprise charges. At least when they ask me to complete forms I can remind them about my fee and they can decide if they really want me to do it. The people who really need PAs that I see are also usually the ones who would have the hardest time affording a fee for completing them.

I can imagine maybe doing this if I had to do an appeal, but I genuinely have not had any PAs denied in the last 2.5 years (except provisionally because they want more notes etc).

 

[Candidate2017]

I've only seen PAs required for things like high dose OCD SSRIs, newer SGAs that cost $3k a month, Ingrezza, Vyvanse and new stimulant formulations that sound like stuff from Star Wars, etc.

I don't get a lot of PA requests because no one ever wants an SGA, much less a new SGA, unless they're a borderline ("I've tried everything, but nothing works!"), no one seems to mind tardive dyskinesia, and no adult wants the Star Wars stimulants because it ain't the Good Stuff.

 

[randomdoc1]

F this absolute garbage. Have been having problems with this med again too which is preposterous as it costs the insurance company less than psychostimulant I was taking them off of. This system is such complete nonsense that I don't even know where to begin with my rage.

xanax and adderall IR ftw (they're so cheap!) LOL

 

[allantois]

I've only seen PAs required for things like high dose OCD SSRIs, newer SGAs that cost $3k a month, Ingrezza, Vyvanse and new stimulant formulations that sound like stuff from Star Wars, etc.

I don't get a lot of PA requests because no one ever wants an SGA, much less a new SGA, unless they're a borderline ("I've tried everything, but nothing works!"), no one seems to mind tardive dyskinesia, and no adult wants the Star Wars stimulants because it ain't the Good Stuff.

Some of these names make me wanna try them (and I don’t have ADHD!) Who doesn’t want some Jornay?