These are the thoughts of a cantankerous ol' gynecologist who remembers when things were a little different. I try to find a little humor in my life and the people I meet along the way. Come meet the characters in my world.

Wednesday, January 18, 2012

Example of “Just a Medicine Refill”:

     1.     Pharmacy faxes refill or patient calls the office

2.     Princess takes a message if pt calls office – patient’s problem, where she can be reached, what medicine, what pharmacy

3.     Princess pulls chart

4.     Princess attaches refill request or note to front of chart and lays it in doctor’s inbox

5.     Dr. Lasermed checks

          A. when patient was last seen (no refills if more than one year for some meds, 6 months for others … by law)

          B. when patient last received the medicine

          C. is it legal to refill over the phone / fax

          D. is there any reason why this patient should not have the medicine now?  Is she overdue for a visit or test?  Should she still have some medicine?

IF the medication is approved,
6. either the fax is filled out, or the pharmacy is called. 

7. There are two separate places in the chart where this needs to be noted – on the progress notes and on our “medication sheet”.  This is a separate part of our chart that has every medication prescribed since the mid 1990s. 

8. The chart is returned to Princess, who checks to make sure all of this was done.

9. A bill is generated if necessary – ya think?

10. The chart is filed.

IF the medication is not approved, the patient and pharmacy are called and an appointment is scheduled. 

This is a SIMPLE medication refill.

Wanna hear about a prior authorization?  I thought not. 


Allison said...

What happened to the world in which if the Doctor prescribed it, it was by definition, medically necessary? Drug insurance companies are just the work of the devil. I take a drug that requires a prior auth AND a quantity over ride. Every year, I apologize profusely and send thank you notes to the staff that deals with my insurer.

pharmacy chick said...

A bill is generated? Wow i wish I could do that! Brilliant! maybe I should take the cue from the airlines and start charging for everything little thing I do. Request PA $__ Request Refill $___ Second request__.
Return to stock fee $__. Extra Bottle Fee$__
we do way to much for free...

Anne said...

I handle the Prior Auths for our office and wrote this while I was on hold with an insurance company just last week. It is in no way exaggerated...

1. Physician sends a prescription to the pharmacy for a medication you really need. Often this is a medication you have been taking for years.

2. The Pharmacy receives the prescription request and turns in a claim to your insurance, which is promptly denied. It's unsaid, but it's because there's a cheaper medication available. Note I said cheaper, not better.

3. A notice that a "prior authorization" is needed is sent from the pharmacy to the physician's office.

4. Someone at the physician's office (at our office, this is me) must find out which prior authorization form needs to be turned in. There are different and sometimes multiple forms for each insurance company and each medication. Send the wrong one and it will end up in the trash pile with no notification.

4a. Usually I can find the correct form online, but on those occasions where I have to call the insurance company, I will be transferred at least twice and have to give the patient and office information to the automated attendant as well as each person I speak with. The call will take no less than 20 minutes.

5. The prior authorization request form is 1-2 pages. The physician has to answer all their questions to justify why you need this particular medication instead of the cheaper (but not better) medication.

6. The form is faxed back to the insurance company.

6a. With certain insurance companies, the above is actually a PRE prior authorization process. After sending in the first form, the insurance company will approve the request to offically START a prior authorization. A second form will be faxed to the physician's office, and the physician must answer the questions on that form and provide a written explanation as to why you cannot just take the cheaper (but not better) medication.

Minutes, hours, days pass....
In the interim, the pharmacy will often fax a notice that a prior authorization is needed again, because someone at the insurance company told them if we would just call they will approve it immediately. I have been able to accomplish this exactly once. In 2 years.

The insurance company approves the prior authorization, thus agreeing to pay for your medication for a specified time period (usually 6 months or one year), after which time we'll have to go through the above process all over again. Another hour will pass before the pharmacy is notified.


Insurance denies the prior authorization with an obscure denial message and two pages of instructions on how to appeal their decision. In the meantime, you must pay 100% for the medication, or the physician must write a new prescription for the cheaper (but not better) medication your insurance WILL pay for.

lasermed said...

@pharmacychick - we started charging for refills several years ago. Patients have enough medication when they leave my office until they are due for their next visit. Since this is such a pain, we charge. We tell them before we do it, so they have the option to come in for their annual and get a years worth of medicine if they want.

@ Anne - I feel your pain. I could write a couple of pages on prior authorizations. But that's a whole other article.