Prior Authorizations (a rant).

[MindOverMatter]

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There is little that irrates me more in the medical industry than the prior authorization fiasco. Insurance companies in today’s society are operating under the presumption that they know more than the doctors about what is right for a patient. To call it ludicrous would be a gross understatement.

At least 5 times a day I am confronted with this situation: a patient comes in to the pharmacy directly from the doctors office. They hold a prescription in their hand. I take in the prescription, type it up, only to find that it’s a prior auth. Most of the time, the patient will still be in the store, so I call them back to my window, and let them know the news. Basically it goes like this: “I’m sorry sir/ma’am, but your insurance company is refusing to cover this medication. They’re requesting that your doctor call them before we can fill this for you.”

Of course they don’t understand. Their doctor prescribed this medication for them, yet their insurance won’t cover it? I then go on to explain that their insurance company is requesting their doctor to call them to demonstrate the necessity of this medication before they will cover it. Blah blah blah, we all know the routine.

My question is this: Who are they to dispute what a doctor decides is right for their patient? What direct knowledge do they have of this patient’s condition? Why does the doctor have to take more time out of his day to deal with this (likely on a daily basis)?

The answer is glaringly obvious: Money.

I know this, and I know this is nothing new. I just want to know, how do you guys deal with it? Does is infuriate anyone else?

Rant over.

 

[acetyl]

It feels like you're hijacking someone's style here, but I feel the same way. Like I've said before, it's the golden rule. He who has the gold makes the rules.

 

[Cocogirl]

Many doctors prescribe inappropriately after being influenced by having too many "free" drug rep dinners and all-paid for vacations to Mexico. The drugs they prescribe are sometimes triple the price of cheaper alternatives. While I'm not endorsing insurance companies' practices, since their motives are less than noble, they do ultimately end up saving general healthcare money by forcing doctors to pay attention to the medications they prescribe. If for some reason, the patient is unable to take a 1st or 2nd line drug, they can still receive the medication with a "prior authorization". This is an extra hoop for all involved (doctor, patient and pharmacist, of course) - but may not be entirely unreasonable.

The ultimate offenders are the drug companies that charge exorbitant prices for drugs to begin with. The insurance companies are under pressure to control their costs while trying not to raise insurance premiums for corporations with whom they contract, who would ultimately end up raising the premiums of their employees - ie. you and me.

Most insurance companies have formularies that are created and tiered based on current disease state guidelines. They generally tend to be evidence based since they need to be able to support their denying medications to consumers if ever taken to a court of law.

I love how no matter how stinky the system gets, the original prescriber (usually a doctor receiving perks and not keeping up on primary literature) gets away smelling like roses each time. 🙁

 

[MindOverMatter]

Wow, thank you Cocogirl. Very good response.

Perhaps I was being a bit naive about it, since I am only viewing this from one angle.

Now my question is this: Doctors must know about these formularies, and ultimately the extra strain they place on their patients when they prescribe these medications, right?

Are the free dinners that good that they will continue to write scripts for drugs when they know their patients will have to wait days before they can physically receive their medication?

I'm just looking out for the little people, and something still smells funny to me.

 

[twester]

Are the free dinners that good that they will continue to write scripts for drugs when they know their patients will have to wait days before they can physically receive their medication?

Yes, the dinners are that good. I once spent personal time with a prescriber who was always inviting me to go to these events with him (I declined based on principle, which was a "feature" of our relationship). The dinners were held at expensive restaurants and even included one pharma company renting out a whole civic aquarium w/dinner included. All for prescribers.

There's a lot fishy about the pharmaceutical industry (a 30 day supply of Zofran at $2,300?). I understand the whole "R&D costs us a bundle" argument, but to say that the industry will close shop if we regulate costs to a more reasonable level is not logical. That's not how capitalism works.

 

[ZpackSux]

You won't have to deal with PA at a hospital pharmacy.

 

[tussionex]

i second that, zpak!👍

 

[KARM12]

Wow, thank you Cocogirl. Very good response.

Perhaps I was being a bit naive about it, since I am only viewing this from one angle.

Now my question is this: Doctors must know about these formularies, and ultimately the extra strain they place on their patients when they prescribe these medications, right?

Are the free dinners that good that they will continue to write scripts for drugs when they know their patients will have to wait days before they can physically receive their medication?

I'm just looking out for the little people, and something still smells funny to me.

There are thousands of different insurance plans and they all cover different medications. There is no way a doctor can know which medicines are covered on every single plan. The same way we in the pharmacy don't know if it will be covered or not. So yes either the patient can pay for it, wait for the prior auth, or hope their doctor will change it.

Some medications are repeat offenders to needing a prior auth because of their high costs. But some medications you can't always predict...ie they want you to try generic Zantac before they will cover Protonix.

 

[rxlynn]

Whenever I get in this situation, I like to suggest to patients that, in the future, they should obtain their own copy of their current formulary and take it to the doctor's office with them. That one simple thing would probably avoid at least some of the PA problems.

As the other poster pointed out - certainly the doctor's offices know that the formularies exist, but there is really no way that they can keep track of which insurance pays for what. However, I have often thought that the offices should be expected to know certain things, i.e. if you are a pediatrician dealing with a lot of state medicaid patients, you ought to know that they won't pay for Xopenex without a PA because it's brand-only.

And, I have to admit that I am on the side of the insurance companies for some of these. I mean, should any insurance really be paying for Clarinex, for example???

 

[LizUMD]

Amen to whoever said that the simplest way to resolve this problem is for patients to be aware of their formulary restrictions, and ideally bring a copy of their formulary with them to the physician to be kept in their chart. And to bring a new one each year when it changes.

I think after awhile most doctors get to know the drug limits involved with the state medicaid plans. However, they change as frequently as every four months. It is not true that all brand drugs without generic equivalents are restricted. You do start to catch on after awhile that Zyrtec and Nexium are almost always denied.

When you're talking about commercial insurance, forget about it. Take Aetna, for example. They have about twenty or so different products with different premiums (HMO, Open Access, Aexcel, etc.) and within each plan type there are six to eight different pharmacy plans with different premiums (Single through Five Tiers, Open and Closed, etc.) That's dozens and dozens of potential formularies for patients just within a single insurance company.

p.s.- Please don't make the assumption that doctors are prescribing certain expensive drugs because they're getting free vacations to Mexico. That is absolutely absurd. Drug reps are a pain in the ass and 90% of physicians would prefer not to have to deal with them, but they need the samples. I think the majority of docs deserve a little more credit than that. There are plenty of legitimate reasons- first and foremost being that the patient has already tried and failed with the preferred or first line drugs. An individual example could be with a pregnant woman. You want to prescribe Zyrtec instead of having her use OTC Claritin like the insurance company wants because Claritin is Cat-C and Zyrtec is Cat-B for pregnant/lactating mothers. Of course once you inform the insurance company of this they always cave and authorize it, but its a monumental administrative headache to accomplish that. You have to spend ten minutes on hold with the insurance just to figure out that company's procedure (fax form? call center?) and then additional time filling out and faxing in their forms (which of course three days later they have no record of receiving) or spend another ten minutes on hold just to justify to a pharmacy tech staring at a computer algorithm why you have prescribed it.

I don't completely disagree with the notion of step therapies and P.A. as a whole for cost-saving measures, but they need to streamline or automate the administrative end of obtaining these.

 

[MacGyver]

Actually what we need to do is ELIMINATE the private insurance industry and have ONE SYSTEM OF REGS from the federal government regarding which medications the public system will pay for.

That way docs dont have to memorize 50,000 systems of regs by each insurance company and that will streamline this crap and eliminate the vast majority of "inappropriate" scripts.

A nationwide federal system of electronic prescribing, with warning boxes that pop up showing cheaper generics available at the time of the prescription would save billions and billions of dollars in wasted money and efficiency.

 

[MountainPharmD]

One of my techs called a Doctors office to request a prior auth. The Docs office said they charge $25.00 and the patient has to pay before they will do it. I thoght that was interesting.

I figure if the insurance company is paying the bill then they have a right to say what they will and will not pay for. I have told many a patient, "You can have what ever your Doctor prescribes if you want to pay cash for it."

 

[Aznfarmerboi]

Yes, the dinners are that good. I once spent personal time with a prescriber who was always inviting me to go to these events with him (I declined based on principle, which was a "feature" of our relationship). The dinners were held at expensive restaurants and even included one pharma company renting out a whole civic aquarium w/dinner included. All for prescribers.

There's a lot fishy about the pharmaceutical industry (a 30 day supply of Zofran at $2,300?). I understand the whole "R&D costs us a bundle" argument, but to say that the industry will close shop if we regulate costs to a more reasonable level is not logical. That's not how capitalism works.

Thats bull**** if you believe that R&D costs us a bundle. In reality, its the taxpayer who pays for the R&D. What we should be looking at is the cost of "advertisement" for the drugs and the hundreds and up to thousands of sales people who get paid 100k+ to sleep with the doctors and "book up expensive restaraunts".

 

[dr of rx]

Claritin is Cat-C

I thought it was category B 😕

anywho, as with 98% of problems, it starts with the dumba** patient.

he/she runs to the doctor with no knowledge of their insurance except he/she "is covered."

If they took just a little responsibility the whole process would be improved.

 

[LizUMD]

I thought it was category B 😕

anywho, as with 98% of problems, it starts with the dumba** patient.

he/she runs to the doctor with no knowledge of their insurance except he/she "is covered."

If they took just a little responsibility the whole process would be improved.

I humbly recant. It is indeed Cat-B. Allegra as I now recall was the preferred insurance rx, after she had tried (and in her words, failed*) the loratadine. And Allegra is the one that is Cat-C. My mistake.

* I often wonder how many of the patients who are advised in the office "your insurance needs you to purchase OTC loratadine first and use it for at least thirty days, if that doesn't work come back and we can document it then request coverage for your Zyrtec" are really going out and doing that. They all come back at their next follow up and claim it isn't helping. How the hell does anyone know if they ever bought it or not? I can't recall a single patient being advised to do this and coming back a month later to say "hey, you know, I bought the Claritin and it really did help! I don't need the rx anymore after all!" I'd be in for a good shock if that ever happened.

 

[LizUMD]

One of my techs called a Doctors office to request a prior auth. The Docs office said they charge $25.00 and the patient has to pay before they will do it. I thoght that was interesting.

I figure if the insurance company is paying the bill then they have a right to say what they will and will not pay for. I have told many a patient, "You can have what ever your Doctor prescribes if you want to pay cash for it."

That kind of thing is only going to become more common.

Docs offices are getting swamped (just like all the other health professions, I'm sure) with more and more time-consuming administrative tasks like prior authortizations for imaging and pharmacy, increased demands for documentation before insurance will pay a claim, increasing levels of paperwork that companies are now requiring for FMLA, sick bank leave and increased demands for supporting forms and documentation for disability applications and auto accident claims, etc. Its getting out of hand.

I know of more than one doctor in the past year who has put up a "menu" of administrative services in their lobby with corresponding costs. Ex.- filling out DMV forms for handicap tags, $10.00; filling out child camp physical forms, first one free and additional forms $20.00 each; completing disability forms, $35.00; FMLA forms, $25.00; generating a narrative report of your condition for a lawyer or auto/workman's comp insurance, $50.00 and up. I know it seems greedy and patients don't like it, but they'll never realize how much more time and effort has to be devoted to these things compared to a decade or two ago. Any other professional, like a lawyer or accountant, would bill by the minute for doing additional services like these. People try to complain "I and/or my insurance already paid the doctor for the visit!"... and yes, that fee was paid for the evaluation, diagnosis, treatment and/or management of your disease or injury. The office visit doesn't include filling out your extensive paperwork.

A common perspective is this: the doctor practices medicine, not insurance. Their job, in part, is to prescribe an appropriate treatment for your condition. Their job really isn't to make arrangements for you to be able to pay for them. For someone who really, truly needs the medication or test in question, then the staff should be happy to help them out. For the bullsh*t people who need their Zyrtec (see above message) or Nexium, when we know with 99% certainty that loratadine or prilosec would probably work just fine... nuh-uh.

 

[Doctor M]

That kind of thing is only going to become more common.

Docs offices are getting swamped (just like all the other health professions, I'm sure) with more and more time-consuming administrative tasks like prior authortizations for imaging and pharmacy, increased demands for documentation before insurance will pay a claim, increasing levels of paperwork that companies are now requiring for FMLA, sick bank leave and increased demands for supporting forms and documentation for disability applications and auto accident claims, etc. Its getting out of hand.

I know of more than one doctor in the past year who has put up a "menu" of administrative services in their lobby with corresponding costs. Ex.- filling out DMV forms for handicap tags, $10.00; filling out child camp physical forms, first one free and additional forms $20.00 each; completing disability forms, $35.00; FMLA forms, $25.00; generating a narrative report of your condition for a lawyer or auto/workman's comp insurance, $50.00 and up. I know it seems greedy and patients don't like it, but they'll never realize how much more time and effort has to be devoted to these things compared to a decade or two ago. Any other professional, like a lawyer or accountant, would bill by the minute for doing additional services like these. People try to complain "I and/or my insurance already paid the doctor for the visit!"... and yes, that fee was paid for the evaluation, diagnosis, treatment and/or management of your disease or injury. The office visit doesn't include filling out your extensive paperwork.

A common perspective is this: the doctor practices medicine, not insurance. Their job, in part, is to prescribe an appropriate treatment for your condition. Their job really isn't to make arrangements for you to be able to pay for them. For someone who really, truly needs the medication or test in question, then the staff should be happy to help them out. For the bullsh*t people who need their Zyrtec (see above message) or Nexium, when we know with 99% certainty that loratadine or prilosec would probably work just fine... nuh-uh.

Amen to this! Why shouldn't MD's and Pharmacies get paidfor extra services. I have a booklet full of PA's at work! It gets out of hand during snowbird season! I bet if we charged $5-10 for each PA we had to send the pt's would be more inclined to see what was covered under their plan. Why should administrative services be free? It takes me or my tech time to send that paperwork over. Have to fill in all the info and send over. Yes, it may take 5 minutes to do, but thats just 1 PA. Let start charging for the services we render! We practice pharmacy, not ins.
Dr.M

 

[dr of rx]

A common perspective is this: the doctor practices medicine, not insurance.

amen to that.

I've told people "when I get paid, it does not say 'Caremark (or whatever insurance company)' at the bottom of my check." I usually get a blank stare...

I want to create a menu of fees:

1) $10 to call for mail order over-ride (because you're too dumb to send away in time)

2) $20 to call your ins company because the scrap of paper with numbers written in crayon don't 'pull up' your insurance.

3) $20 misc hand-holding charge. Examples include vacation over-rides, lost med over-rides, etc.

4) $10-20 for OTC or RX info above and beyond usual questions (I won't answer the same 3 questions for 20 minutes). Also, if you did not buy the RX from me and or start out by saying "I always go to Wal-Mart but they are closed.." I will add an extra $15.

5) $20 for off the wall, odd hour phone questions. For example, if you must call me after everyone else is closed and question how to get rid of maggots in your waste basket (ture story...I said get a new waste basket!!).

6) $10 fee for in-store hand-holding. For example, if I say the Prilosec is in isle 10, half way down, a huge display in purple boxes you'd better find it. If I have to come out and show you, pull out your cash.

I am sure I could go on...

Most of these are jokes, but I am sure you all get the point!!

 

[LizUMD]

You know, I'm reminded of a fiasco with a patient about a month ago over a prior-auth. It was for her new prescription of phentermine (yes, they are even starting to require prior-auths for some generic drugs now). This woman was such a PITA about it, calling twice a day the entire week to see if we'd gotten the approval yet. Of course, her particular plan would only accept fax forms, which can take up to a week to get a reply on. Anyway, her request came back denied- she didn't have enough comorbidities. Of course, she was pissed not at her insurance but at our failure to "help her out."

Turns out, she went back to the pharmacy and decided to purchase the drug for cash price. Total cost? $31.50, or something like that. Her co-pay, had the drug been approved for coverage? $25.00. Our office manager heard the story from her at follow up, and all I could think was... are you freaking kidding me? Our staff spent all that time calling in to get a form, filling it out, tracking it, calling back to the insurance twice to try to get an update (total hold, call and work time about a half hour to an hour)... just so you could save six bucks? GMAB.

 

[pion]

All too common, LizUMD! There have been so many times that I ring up a patient for a script that's $11.99 and they freak out because their copay is $10.

"OK can I see your insurance card?"

(Indignant) "You can look that up! I didn't bring my card with me! WHY WOULD I DO SUCH A THING?!"

(10 minutes on hold with the insurance company while a line of angry customers forms)

I usually have to resist the urge to just give them two bucks from my own wallet.

 

[Doctor M]

You know, I'm reminded of a fiasco with a patient about a month ago over a prior-auth. It was for her new prescription of phentermine (yes, they are even starting to require prior-auths for some generic drugs now). This woman was such a PITA about it, calling twice a day the entire week to see if we'd gotten the approval yet. Of course, her particular plan would only accept fax forms, which can take up to a week to get a reply on. Anyway, her request came back denied- she didn't have enough comorbidities. Of course, she was pissed not at her insurance but at our failure to "help her out."

Turns out, she went back to the pharmacy and decided to purchase the drug for cash price. Total cost? $31.50, or something like that. Her co-pay, had the drug been approved for coverage? $25.00. Our office manager heard the story from her at follow up, and all I could think was... are you freaking kidding me? Our staff spent all that time calling in to get a form, filling it out, tracking it, calling back to the insurance twice to try to get an update (total hold, call and work time about a half hour to an hour)... just so you could save six bucks? GMAB.

The fact is that INS companies are not going to go away, ever. We need to start charging for services that we render. Why should i or my staff take 5 minutes for each PA when we could be filling or counseling patients. The way I see it, patients need to start being held accountable for their own healthcare. I fill and counsel the patient and recommend products, that is what i had higher education and $90 k in loans. I did not spend 4 yrs in school to be doing PA's all day. It is just ridiculous!

Dr. M

 

[Doctor M]

You know, I'm reminded of a fiasco with a patient about a month ago over a prior-auth. It was for her new prescription of phentermine (yes, they are even starting to require prior-auths for some generic drugs now). This woman was such a PITA about it, calling twice a day the entire week to see if we'd gotten the approval yet. Of course, her particular plan would only accept fax forms, which can take up to a week to get a reply on. Anyway, her request came back denied- she didn't have enough comorbidities. Of course, she was pissed not at her insurance but at our failure to "help her out."

Turns out, she went back to the pharmacy and decided to purchase the drug for cash price. Total cost? $31.50, or something like that. Her co-pay, had the drug been approved for coverage? $25.00. Our office manager heard the story from her at follow up, and all I could think was... are you freaking kidding me? Our staff spent all that time calling in to get a form, filling it out, tracking it, calling back to the insurance twice to try to get an update (total hold, call and work time about a half hour to an hour)... just so you could save six bucks? GMAB.

Anti-obesity drugs are usually (99.999999%) never covered. I wouldn't bother next time. Anyway, what a waste of your time! I hate that when they call 3 to 4 times per day!! Stop calling!!!! 😱

 

[dr of rx]

The fact is that INS companies are not going to go away, ever. We need to start charging for services that we render. Why should i or my staff take 5 minutes for each PA when we could be filling or counseling patients. The way I see it, patients need to start being held accountable for their own healthcare. I fill and counsel the patient and recommend products, that is what i had higher education and $90 k in loans. I did not spend 4 yrs in school to be doing PA's all day. It is just ridiculous!

Dr. M

I'll tell you why it won't change....because the big corp chains will do anything for business. Since they will all never come to an agreement together (to charge for service) it will never happen. They'll continue to get every last ounce of enegy outta you and I for as little as possible. Unless we all wise up and do something....

I can hear the complaints already...."BUT WAL-MART NEVER CHARGED TO CALL MY INSURANCE!!" wawawawa


Imagine the advertisements...."At Wal Greens, we value your health and business. That is why we'll call your insurance, your Dr, and your mommy free of charge...."

It is never gonna change.

 

[Doctor M]

I'll tell you why it won't change....because the big corp chains will do anything for business. Since they will all never come to an agreement together (to charge for service) it will never happen. They'll continue to get every last ounce of enegy outta you and I for as little as possible. Unless we all wise up and do something....

I can hear the complaints already...."BUT WAL-MART NEVER CHARGED TO CALL MY INSURANCE!!" wawawawa


Imagine the advertisements...."At Wal Greens, we value your health and business. That is why we'll call your insurance, your Dr, and your mommy free of charge...."

It is never gonna change.

I know it wont, it was just a rant🙁 These corporations will do whatever it takes to get a penny. Again, it is just ridiculous.