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The views and opinions expressed herein are those of the author and do not necessarily reflect those of BehaveNet, Inc.

02/04/2016

A recent request for prior authorization (PA) for Concerta, apparently from PBM Envision/Rx wasted my time and left the patient in limbo and angry at me.

I have no objection to insurance companies limiting cost to keep premiums down, or even to increase profits, but they just hurt themselves when they force providers to waste time on futile exercises and leave their subscribers in a quandary.

Both PBM and pharmacy may mislead their customers into thinking that prescribers will drop what we are doing and immediately answer all their questions in such a way that they will authorize payment for the drug, and everyone will be happy.

Not exactly.

When I receive a request for PA of a drug, I require the patient to sign my own authorization agreement. I offer to provide a copy of the medical record at no charge. For a non-refundable $50 fee (in advance) I will complete the PA process with no guarantee of success. (I have been waiving the fee if I can get the pharmacy to initiate the PA through covermymeds.com.) Such financial matters do not get urgent attention from me. In fact, if I were out of town on vacation they would wait until my return.

Keep in mind that I have no contract with the payer. My contract with the patient obligates me to provide only medical care to the patient. I do not agree to get money for the patient's other medical needs.

Questions posed to me in this PA:

  • "Have other formulary alternatives in this drug category/class been tried and failed?"
    • I have no access to the formulary, nor do I want such access.
    • Pleas define “failed.”
  • "Please list them below along with the date the medication was tried and failed."
    • I will only provide such information as pertains to medications tried since I started caring for the patient.
  • "If the patient is unable to tolerate the formulary alternative, what is the issue the patient is having?"
    • “Issue”?
      • I have no idea what they mean by that. If they want to know about adverse effects, or lack of improvement, they can use the appropriate terms.
    • “Is having”?
      • Do they really think the patient still suffers from some problem. More likely it occurred in the past leading to change to the new medication.

Note that so far the patient can answer these questions at least as well as the prescriber and possibly better.

  • "For medical necessity reviews, you must provide a unique peer-reviewed journal article to support your request for off-label use, Please attach any medical information that may support approval."
    • Again, my role does not include medical librarian duties for an insurance company.
  • "Please provide any supporting clinical statements (such as lab values, adverse outcomes, treatment failures, or any other additional clinical information to support a formulary exception request)"
    • Fair enough, provided these happened on my watch.

PBMs should warn patients in advance of the need for PAs, possibly covering a single one month supply without question.

They should obtain any information known to the patient from the patient.

They should obtain information from prior providers’ records directly from those providers.

I believe providers will increasingly refuse to cooperate with these reviews. Instead, we can provide copies of the medical record and let the payer decide whether or not to pay.

Patients should know their contracts and demand their insurance companies pay as promised. I know of no provider who promises to get reimbursement for drugs for every patient. Obtain your own copy of your record from each past provider so you can share it with your insurer. Be proactive: When you change insurers, take a copy of their formulary to an appointment so you can discuss whether to try a different drug, regardless of whether the company pays for it. Do not hold it against your provider if the insurer refuses to pay. Hold it against the insurer. Better yet, find out the extent to which a new potential insurer will cover your medical needs before you sign up with them.

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