Dismiss Notice
Hey Texans—join us for a DFW meetup! Click here to learn more.

Prior Authorization Declined

Discussion in 'Psychiatry' started by F0nzie, Aug 6, 2015.

  1. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    Prior authorization needed for Fluoxetine 10mg 1.5 tabs po daily. Prior authorization declined due to quantity limit of 30 for the plan. Please submit an appeal. 1 hour later... we appreciate you calling. Please continue to hold. Good times.
     
  2. Note: SDN Members do not see this ad.

  3. wolfvgang22

    Physician 10+ Year Member

    Joined:
    Jun 14, 2004
    Messages:
    1,171
    Likes Received:
    1,345
    Status:
    Attending Physician
    Who the hell requires a prior authorization for generic fluoxetine at all?
    Sounds like some crappy "managed medicaid" third party insurance company rule. Jeez! Queue the muzak.
    I bet if you just prescribed 20mg it would be fine, because then you'd need only 30 pills. Who cares if the patient's liver is trashed, is 85 years old, or 5 years old, or on other meds...
     
  4. milesed

    5+ Year Member

    Joined:
    Jun 25, 2011
    Messages:
    371
    Likes Received:
    154
    Status:
    Attending Physician
    we get that all day, csend in an appeal to be told,"PA is not required for fluoxetine". UGGGGGGGG!!
     
    nitemagi and wolfvgang22 like this.
  5. st2205

    st2205 Attending
    10+ Year Member

    Joined:
    Oct 28, 2006
    Messages:
    1,803
    Likes Received:
    1,031
    Status:
    Attending Physician
    Part of the thing that chaps my ass is that we, as a society, are so dependent on our insurance that we couldn't bear the thought of paying for the $4 Prozac out of pocket. A couple weeks ago I had a PA for hydroxyzine and they ran through a list of medications, asking if the patient failed them. They included a few meds that are much more expensive. And none of them were PRNs. It'd be easier to give the patient $10 every time they leave the office and tell them to pay cash.
     
  6. MacDonaldTriad

    5+ Year Member

    Joined:
    Mar 13, 2013
    Messages:
    1,941
    Likes Received:
    2,827
    Status:
    Attending Physician
    I’ve been tempted to tell patients to get off insurance because the indigent/uninsured poor formulary is much better.

    With all of the historical attempts to get one system to help support the other while the first system trying to control costs, it is a wonder it isn’t even worse. I guess you could argue that it isn’t working, but with so many bright people trying to create work arounds while well-resourced commercial entities are trying to plug loop holes, it does make for good theater sometimes.
     
    Psyche Estrelle likes this.
  7. Doctor Bagel

    Doctor Bagel so cheap and juicy
    Moderator Emeritus 15+ Year Member

    Joined:
    Sep 26, 2002
    Messages:
    10,919
    Likes Received:
    1,114
    Status:
    Attending Physician
    This. It's almost as if people don't get that they can occasionally pay for care themselves, assuming they're not broke and that the care is reasonably priced. Most people could pay for fluoxetine without insurance support. Sucks that a doctor has to spend hours of time for a prior authorization. Could you just refuse to do it? Or charge for the time?
     
  8. Shikima

    Physician 10+ Year Member

    Joined:
    Oct 15, 2006
    Messages:
    4,526
    Likes Received:
    2,634
    Status:
    Attending Physician
    You know you can bill them for being on hold.
     
  9. JustaPD

    2+ Year Member

    Joined:
    Sep 21, 2014
    Messages:
    1
    Likes Received:
    3
    It's because you ordered tablets instead of capsules. Capsules are $4. Tablets much more expensive.
     
  10. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    Appeal denied! We're going for the epic final round... Dum dum dummm... Formal written letter with medical justification. The excitement is out of control!
     
  11. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    I'm covering for my wife. It's a child psych case. Kid had too many side effects going from the 10mg to 20mg capsule. Child psych sucks. Jk.
     
    OldPsychDoc likes this.
  12. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    I honestly didn't think it would take this long. But once I fell down the rabbit hole I wanted to see what was behind those tiny doors.
     
    Nasrudin, Shikima and GroverPsychMD like this.
  13. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    On a side note I was able to get the liquid formulation approved so they can titrate it but nooooo they want the tablets. :p
     
    GroverPsychMD and heyjack70 like this.
  14. psych md jd

    psych md jd Better safe than sorry.
    5+ Year Member

    Joined:
    Jun 12, 2012
    Messages:
    199
    Likes Received:
    206
    Status:
    Attending Physician
    PA's in forensic land get quite interesting.

    I called for Prozac on a pt. with pedophilia. It was started in the state hospital so I didn't know what had been tried before. I requested an urgent review and was told it could take up to 48 hours to get a decision. Literally 15 minutes later I get a fax approving an unlimited # of refills.

    Of course, a few weeks later he is exposing himself in public and goes back to the hospital.
     
    GroverPsychMD likes this.
  15. birchswing

    birchswing Patient/Interested in Psychiatry
    5+ Year Member

    Joined:
    Nov 17, 2011
    Messages:
    1,352
    Likes Received:
    471
    Curious: Why not prescribe 20 mg with the understanding of taking 1.5 tablets? I guess the main reason would be if the patient taking the medicine was easily confused or couldn't remember what they were supposed to take.

    I take bisoprolol and the lowest dose available is 5 mg, but I know that my cardiologist wants me to take 1.25 mg so I quarter the pills. And during a benzo taper it would be impossible to rewrite the prescription every time you chip off a half or quarter.
     
  16. WingedOx

    WingedOx Unofficial Froopyland Forum Mod.
    Gold Donor 7+ Year Member

    Joined:
    Nov 16, 2010
    Messages:
    7,287
    Likes Received:
    11,198
    Status:
    Attending Physician
    And yet people complain that the VA ("workin' for the guv'mint") has too much bureaucracy and paperwork...
     
    Nasrudin and wolfvgang22 like this.
  17. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    That pension!
     
  18. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    I see you have modified your disclaimer.
     
  19. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    I wrote one of these letters. Never heard back. And neither did the patient. And it still wasn't covered...
     
  20. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician
    lol I just got a fax back indicating that it was "not processed. See notes below". It indicated that my letter was rejected based on initial rejection of the prior auth. Great tactics by insurance companies: create a loop-- enter here. What a scam.
     
    Comanaprocil and GroverPsychMD like this.
  21. Doctor Bagel

    Doctor Bagel so cheap and juicy
    Moderator Emeritus 15+ Year Member

    Joined:
    Sep 26, 2002
    Messages:
    10,919
    Likes Received:
    1,114
    Status:
    Attending Physician
    Dude, they are going to take the liquid formulation, and they're going to like it!
     
  22. splik

    splik Professional Cat at Large
    Physician Faculty 7+ Year Member

    Joined:
    Nov 30, 2009
    Messages:
    3,567
    Likes Received:
    4,394
    Status:
    Attending Physician
    sorry i have no sympathy for you you are too nice. unless you are billing them for the time to get PA. they can pay the $10 out of pocket.
     
  23. MySpirit

    Joined:
    Jun 22, 2015
    Messages:
    26
    Likes Received:
    9
    I noticed a few times that when patients had to pay, they quickly say that the med either doesn't help them or they come up with side effects that are at the top of the list of usual side effects.
     
    GroverPsychMD likes this.
  24. keifernny2

    5+ Year Member

    Joined:
    Aug 26, 2013
    Messages:
    257
    Likes Received:
    155
    Status:
    Attending Physician
    Usually with the long half-life of fluoxetine, I have them alternate when they can't tolerate the higher dose. They could take 10mg capsules MWF and 20mg T/TH/S and, on Sundays they flip a coin.
     
  25. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    Yep.
     
  26. Shikima

    Physician 10+ Year Member

    Joined:
    Oct 15, 2006
    Messages:
    4,526
    Likes Received:
    2,634
    Status:
    Attending Physician
    Where did the insurance companies learn this behavior from?


    Answer: CMS.
     
    mgdsh likes this.
  27. RomanticScience

    7+ Year Member

    Joined:
    Jun 19, 2009
    Messages:
    79
    Likes Received:
    50
    Status:
    Attending Physician
    PistolPete likes this.
  28. F0nzie

    Physician 5+ Year Member

    Joined:
    Aug 22, 2011
    Messages:
    1,621
    Likes Received:
    1,217
    Status:
    Attending Physician

    Interesting. I'll definitely check it out!
     
  29. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    The insurance company said they "didn't get my appeal letter".
    I have proof the fax was successful..
     
  30. WingedOx

    WingedOx Unofficial Froopyland Forum Mod.
    Gold Donor 7+ Year Member

    Joined:
    Nov 16, 2010
    Messages:
    7,287
    Likes Received:
    11,198
    Status:
    Attending Physician
    that ain't going away any time soon though.
     
  31. PistolPete

    Physician 10+ Year Member

    Joined:
    Jul 16, 2006
    Messages:
    1,934
    Likes Received:
    403
    Status:
    Attending Physician
    Awesome, thanks so much. I'll definitely be using this a lot.
     
  32. Shikima

    Physician 10+ Year Member

    Joined:
    Oct 15, 2006
    Messages:
    4,526
    Likes Received:
    2,634
    Status:
    Attending Physician
    And it will only get worse with managed care.
     
  33. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
    Physician Moderator Emeritus SDN Advisor 10+ Year Member

    Joined:
    Dec 2, 2004
    Messages:
    6,121
    Likes Received:
    3,513
    Status:
    Attending Physician
    They don't care...
    :mad:
     
  34. WingedOx

    WingedOx Unofficial Froopyland Forum Mod.
    Gold Donor 7+ Year Member

    Joined:
    Nov 16, 2010
    Messages:
    7,287
    Likes Received:
    11,198
    Status:
    Attending Physician
  35. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    And to boot, the patient is mad with me! I showed her the proof that it was sent successfully..
     
    F0nzie likes this.
  36. whopper

    whopper Former jolly good fellow
    Physician Faculty 10+ Year Member

    Joined:
    Feb 8, 2004
    Messages:
    6,640
    Likes Received:
    1,284
    Status:
    Attending Physician
    One of my colleagues came up with an idea of informing the patient of the name, location, and contact information of the doctor that refuses the prior authorization so that this doctor could be reported to their state medical board for violation of ethics if they refuse a prior authorization that blatantly should've been approved.

    Only reason why I haven't done this yet is cause I haven't reviewed the laws and regs to see if this is allowed and not violating some type of regulation.
     
    Therapist4Chnge likes this.
  37. Psychotic

    5+ Year Member

    Joined:
    Sep 17, 2013
    Messages:
    728
    Likes Received:
    394
    Status:
    Resident [Any Field]
    When you say "billing them," do you mean the patient, or the insurance company reimbursement (or is it effectively both getting billed?)

    I am still just a resident and haven't had to deal with this stuff, but it seems to me that this "admin time" has to be billable both to the patient and especially to the insurance company. Is it? Is there a special code for this? If the insurance company won't reimburse for it (even though they are the cause of it), will patients pay it, and is it generally collectible? Or is the provider just supposed to eat this time, you know, for the privilege of being a physician?
     
  38. splik

    splik Professional Cat at Large
    Physician Faculty 7+ Year Member

    Joined:
    Nov 30, 2009
    Messages:
    3,567
    Likes Received:
    4,394
    Status:
    Attending Physician
    hahaha sorry no insurance companies will not pay for this. this is uncompensated time. but fonz has a cash only practice so should definitely have some way of billing the patient/family for this work.

    in salaried jobs one should try to do as much of this stuff in the session with the patient or make sure there is enough ancillary staff who submits the PAs for you. sadly too many people are spending too much time doing this crap and the insurance companies deliberately make this as tedious and frustrating as possible.
     
  39. heyjack70

    heyjack70 Junior Member
    7+ Year Member

    Joined:
    Nov 24, 2005
    Messages:
    745
    Likes Received:
    245
    I had an annoying experience with prior authorizations. Insurance required prior authorization for Cymbalta about 4 months ago. I called and insurance said pharmacy was billing something like $325 for a month of 60 mg Cymbalta. I called the pharmacy and they told me the cash price was $30 each month. After wasting 20 minutes on the phone with the insurance company arguing about why they can't just pay the $30 price, I told the patient to just pay cash. What really bothers me is the pharmacy charging way more to the insurance company, which is most likely why the prior authorization was required. Then the pharmacy calls me and tells me to do the prior authorization. If I could do it over again, or if I have to deal with this pharmacy again, I would tell them to do the prior authorization if they are charging a premium to the insurance company.
     
  40. splik

    splik Professional Cat at Large
    Physician Faculty 7+ Year Member

    Joined:
    Nov 30, 2009
    Messages:
    3,567
    Likes Received:
    4,394
    Status:
    Attending Physician
    at the same time PA does exist to stop physicians prescribing any crap to patients but it has become a way to deny pts care they need. you get what you deserve if you try and prescribe cymbalta to pts though
     
  41. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    Wrong. It's those greedy doctors keeping healthcare costs high....No one else..
     
    Therapist4Chnge likes this.
  42. TikiTorches

    Physician Classifieds Approved 7+ Year Member

    Joined:
    Sep 12, 2010
    Messages:
    2,980
    Likes Received:
    968
    Status:
    Attending Physician
    I am never able to get this information. It is a faceless and nameless decision made by a pharmacist..or so they say...who knows...
     
  43. whopper

    whopper Former jolly good fellow
    Physician Faculty 10+ Year Member

    Joined:
    Feb 8, 2004
    Messages:
    6,640
    Likes Received:
    1,284
    Status:
    Attending Physician
    Whenever I did a prior-auth for inpatient I had to talk one on one with a doc who had to identify himself.
    It's the prior auths for outpatient where you don't talk to someone that has to identify themself.
     
  44. concrete3739

    Joined:
    Aug 2, 2015
    Messages:
    2
    Likes Received:
    2
    Status:
    Medical Student (Accepted)
    I feel like the insurance companies should have communicate the PA and denial to the patient and not the MD. I always feel like I have to apologize to the patient after I already spent several hours trying to appeal the decision for the insurance company. Last week, after an arduous day of a patient not getting a prescribed med in what she perceived to be a timely manner (24 hour turn around), I actually consciously held back an apology because I felt like I shouldn't be apologizing for the insurance company. But when I saw her in my office, I apologized anyway.
     
    Doctor Bagel and heyjack70 like this.
  45. Shikima

    Physician 10+ Year Member

    Joined:
    Oct 15, 2006
    Messages:
    4,526
    Likes Received:
    2,634
    Status:
    Attending Physician
    It helps to build rapport, if you are genuine.
     

Share This Page