Prior Authorization Declined

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F0nzie

F0nzie

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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.
 
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...
 
we get that all day, csend in an appeal to be told,"PA is not required for fluoxetine". UGGGGGGGG!!
 
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.
 
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.
 
st2205 said:
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.
Click to expand...

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?
 
F0nzie said:
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.
Click to expand...
You know you can bill them for being on hold.
 
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!
 
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.
 
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.
 
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.
 
F0nzie said:
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.
Click to expand...

And yet people complain that the VA ("workin' for the guv'mint") has too much bureaucracy and paperwork...
 
psych md jd said:
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.
Click to expand...

I see you have modified your disclaimer.
 
F0nzie said:
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!
Click to expand...

I wrote one of these letters. Never heard back. And neither did the patient. And it still wasn't covered...
 
GroverPsychMD said:
I wrote one of these letters. Never heard back. And neither did the patient. And it still wasn't covered...
Click to expand...

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.
 
F0nzie said:
On a side note I was able to get the liquid formulation approved so they can titrate it but nooooo they want the tablets. 😛
Click to expand...

Dude, they are going to take the liquid formulation, and they're going to like it!
 
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.
 
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.
 
F0nzie said:
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.
Click to expand...

Yep.
 
The insurance company said they "didn't get my appeal letter".
I have proof the fax was successful..
 
outczarina.jpg
 
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.
 
splik said:
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.
Click to expand...

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?
 
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.
 
heyjack70 said:
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.
Click to expand...

Wrong. It's those greedy doctors keeping healthcare costs high....No one else..
 
whopper said:
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.
Click to expand...

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...
 
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.
 
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.
 
concrete3739 said:
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.
Click to expand...
It helps to build rapport, if you are genuine.
 
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