How, indeed. I deal with it. A page and a phone call at a time.
Let me give you an example. I prescribed a drug that comes in 3ml prefilled pens. The patient needs three pens a month. It needed prior auth. I made the phone call and filled out the form three weeks ago, and got approval for a year. Hooray!
Then I got a fax today from his pharmacy saying he needs prior auth. I called and said it’s been approved. They said his plan will only cover three pens or 9ml for 90 days, which is a third of what he needs. So I call the prescription benefit watchdogs again. They said he is approved for nine pens for 90 days, which truly is sufficient.
So I call and tell the pharmacist. She said it still won’t go through but she will investigate. Then I get the phone call — his insurance says that their interpretation of “nine pens” is “9ml” even though the drug is only available in 3ml pens, so I have to obtain new prior auth that says he needs 27ml for 90 days.
Seriously? I have to waste my time because they can’t do math?
I have also had to write three letters of appeal to get labs paid for, and a letter of appeal to get a continuous glucose sensor approved after they denied it for a man who has needed his wife to give him glucago n, has needed 911, and who has gotten into car accidents because of hypoglycemia.
Ah, I remember the days when you could see a patient, write a brief note, write a prescription or order a test without having to undergo the third degree. Now, you need to write down the minutiae of what you do, make sure the proper ICD-9 codes are on every request, and be prepared to explain that yes, darn it, this med and that test are “medically necessary.”
OK, I am all for curtailing healthcare expenses. I think too many people get MRIs and thyroid antibodies and expensive drugs. Do I have a better suggestion on how to curtail spending? No. But once you’ve submitted 20 pages of your notes detailing the rationale behind your medical decision making, I think your paper-pushing job should be done.
