Home Forums Discussions General Discussion Prior-Authorization.

Medication prior-auths have become the bane of my practice. 30-50% of prescriptions are now bounce backs requiring prior auths. With the radiology prior-auths, at least the chart note can faxed by my office staff which helps with the authorization process. With the medication auths, the office staff has no idea about the ICDs that can be utilized (which are not listed in the note)/prior medications used etc to get an auth. How are you dealing with this? Thank you in advance for your responses.

In our pediatric world, it's rather simple. We, on the rare occasion that scripts are bounced back for prior auth, look for alternate drugs and tell our patients about their insurance shortcomings.
My deepest sympathies.

We use CoverMyMeds.com to complete prior authorizations. Staff can start the authorization, filling out as much information as possible, then notify the provider a request is waiting. She logs in, answers whatever questions staff couldn't, and clicks a button to automatically fax it to the insurance plan. It's easy to use, and we can archive requests once they've been approved/denied so they're available to reference next year when we're asked to complete another PA for the same med.

Of course our preference would be for insurance companies to stop playing games with our patient's medications, but if we have to do them we've found this is the easiest and least time-consuming.

Seems like CoverMyMeds asks for a lot of information just to sign up for prior authorization forms.
Dave

Interesting new resource here.... Funny they don't seem to work with AC's Our "E" Rx vendor one of the larger one's in the country.... Wonder why this is?

I also have to wonder how much the Insurance Carriers are going to cooperate with this at all considering that almost ALL Prior Auth's and any other similar Hoops to Jump are mainly there, probably Exclusively there simply as to create a Barrier to Care which in turns saves them more money for their greedy 25-33% NO ROI worthless @$$'s.....

So let me get this straight... The Private for Profit Insurance System in and of itself is responsible for somewhere between 25-33% of the needless waste and over pricing in the system, and as of the most recent and best research Primary Care is but 5% of our entire healthcare dollars spent..... And yet we continue to allow the Insurance Industry to frame any and all of us as the problem with the costs and complexities of healthcare???? What's Wrong with this Picture?????

Paul

Our provider signed up for it, then sent me the info so I could train staff, so I honestly don't know what they asked for. I do know it's a huge time-saver for us. Even if we have to call to request a form by fax, we're on the phone for at least 20 minutes.

Got a prior authorization request for generic metformin this week from a Medicare "Advantage" plan. It's $4/month at Wal-Mart or free at local grocery Publix. I told patient to just pay cash or get it for free. My staff and me are not going to spend 20 minutes on something that is 13 cents a day.

I don't "prior auth" anything, unless it is absolutely crucial for life. If patients have any questions, I tell them that I am not a marketing representative, and I'm not playing the game whereby the drug companies get to charge higher prices because I whine loudly enough.

If EVERYONE stopped this stupid game, the drug companies would have to lower their prices to a market value that insurance companies would pay, and if insurance companies would say up-front, "you can have anything you want, but there is a premium for certain products" instead of playing the "guess what deals I have cut" game, it would very quickly end.

I tell the pharmacy to give the patient whatever the insurance company wants them to have -- after all, since the omniscient, omnipotent insurance companies have all the money and all the talent and all the power, it is presumptuous of me to question their choices.

Saves me a huge amount of time and frustration, and I haven't had much pushback from patients. The ones that really feel like they have to have whatever the latest TV ad says they should have can go to a more compliant physician.

Prior auth's = increased overhead

We only make one phone call, to the patient. Our staff tells them that their insurance company is holding up filling the prescription by requiring extra paperwork. We give him/her the telephone number and tell them we're willing to fill out a single page form if they will fax this directly to us, but we make the patient request the form.

We had to do it this way, some of the subspecialists were writing prescriptions and then telling the patients to get pre-authorizations from us -- we were fielding over a dozen requests on some days. So we had to get the patient's involved. Besides,it gives them some insight into what we go through with their insurers.

Next time along with making the patients do some of the work here are a few other suggestions. Many IMP's make the patient come in and sit in the exam room with the doc, On Hold and pushed around from one bozo to another, and the patient has to pay their cost sharing to, and let them REALLY See and pay the price too, to have the doc do this. Now at least the doc gets to bill and 3 or a 4 for the time spent doing this. I also know of a local Psychiatrist that has an "ALL things are an office visit policy" forms, refills, prior auths and anything else... this way the patient has some skin it and also this way the insurance carriers are being "Charged" for the doctors time, one prior auth at a time.... It's very good thought and most patients walk away glazed eyes and speechless or infuriated as heck after being a part of it all. Then remind them that they only have to do this for their own healthcare needs and that we have to deal with this kind of crap all day, every day all year long....

The other thing here that tics me off to no end is the specialist dumping the problem on the lower paid, and less respected PCP's... They probably get a nice procedure or in house MRI or some other form of much better payment being the specialist... This is rude and totally disrespectful to the refering Primary. I would send the patient back with the form with a letter you can give basically to all patients, (Template it, right?) that says to the effect you will stop refering patients to their providers if they don't stop this paperwork dumping upon you and your office. You find it highly unprofessional and completely disrepectful of your own role in the patients care and the referal process to boot. Furthermore, you feel that it is bording on Med Mal because you are NOT the doc who requested, suggested, or Rx'ed the Drug and are NOT the Expert Specialist and in many cases may not even know the correct Dx codes and the like that go along with the condition the patient has that started the entire referal two offices working together in the first place process.... And that you will report them to the insurance carrier and the state medical society for not doing your share of the patient care. You believe that the patient should have this med, then they can be the ones to do the paperwork that goes with it...

Honestly, should you have to do their Prior Auth's for their surgical procedures next? They make a few grand off of what you make a couple of hundred bucks prior to either sides office expenses... who is getting screwed here? Would it be any more appropriate for you to perfectly reverse the process and suggest, Rx a med and then tell the patient to go see and bother their specialist for this med because it is a med for the condition that, that specialist is treating them for???? You know and I know that they and their entire snooty staff would have a complete litter of Kittens on you and yours if you were to treat them likewise.... You want it, your write it, you manage it and you do the paperwork that comes with it... plain and simple... They simply want to DUMP on the primary and you should tell their Practice Manager and that doctor Directly that exactly to both of their faces.... I dare them to actually be able to defend it... Like their better off practice shouldn't be imposed upon staff and doctor time wise, but the struggling and overwhelmed PCP that sent them the patient in the first place, they should have to absorb those hits to save them those extra expenses and inconvieniences???? BULL!

We actually have had the patient come in and sit while we hang on hold for their authorization a few times, usually the arrogant ones who think that their cheapo insurance should be our problem.

Not that I need to give another example, but I will :-)
Medicare advantage plan wanted Prior auth for generic Robaxin.
Then another Medicare advantage plan was concerned that I was treating a patient for GERD, who has a BMI of about 55, the heaviest patient in my practice, with generic ranitidine (Zantac) for too long (costs $4/month at Walmart). Currently I don't take new patients with Medicare advantage plans, but am considering dropping existing patients who switch to them.

BTW, my Budesinide EC 3 mgs (qnty 90 btw too I might add)that supposedly cost $1480 "Retail" so says the print-out with the Rx from my local Wegman's Pharmacy.... And that generic too! And it only went generic this year too.... Well for a few moments when I was just starting this new med for my UC and it seemed to be doing the trick without any of the crap from the salisides (some folks are allergic and have reverse symptoms like loose poops and gas, just what we're trying to get rid of, like I did) it seemed we might not have coverage at the end of the month, so...

My Mom who hits the donut hole each year told me about a trick her and her other "Senior" aged Managed Medicare friends make use of to keep costs down... Canada Drugs, dot com... Well my great new super expensive nobody would touch it til it went generic med here in the states anyway, costs but $75 generic just an hour or so north of the Syracuse and even the Name Brand only goes for $212 bucks American as of about 6-8 weeks ago... Now that is a crying shame and a huge blemish on the face of the good old US of A if you ask me....

So why does the American Gov't allow only our own citizens and our healthcare system have to overly absorb such insane price differences when clearly such meds can be produced and distributed at a reasonable profit margin at so much lower prices in other more intelligent, less one percenter nations like our largest trading partner to the north and home to such great free market companies as RIM???? Not exactly a super RED communist nation with hordes spilling over our northern boarder ready to destroy our system of "free markets" now are they???

That's it, I'm done, I'm moving to Canada where my kids can have access to healthcare, really good inexpensive colleges and medicines for most problems we might encounter at a reasonable price... It's well worth the extra cost of gas and beer (calm down now Bert, You'll get used to the Beer thing once you don't see the prior auths on your desk anymore, you won't need 3 beers anymore to calm down and get to sleep anymore...).

You might want to check the income and tax issues - I think you will find that one of the main reasons meds are so cheap in Canada is that the Canadian government subsidizes the cost for its citizens as well as the lack of the product liability for meds sold in that country. My personal opinion is the lawyers and internet sites that make millions off class action lawsuits on meds that help drive the cost up - of course changes in tort laws won't be enacted since the standard degree for lawmakers is JD....

Parasites like John Edwards and his ilk, ex-malpractice lawyer turned politician.