Prior Authorization of a Medication

Insurance companies are deciding more and more which medicines they want to pay for.  They also set limits on how much of a medication patients may have per month.  If the patient needs anything different than what the insurance company (in their infinite wisdom) has decided is the ideal medication, doctors are supposed to get a “prior authorization”.  This used to be simply signing a form.  Times have changed. 

These are the steps that we have to go through for prior authorization of a medication. 

1.      Pharmacy or insurance company faxes prior authorization request the office

2.      Princess pulls the chart

3.      Princess attaches PA to front of chart and lays it in doctor’s inbox

4.      Dr. Lasermed checks

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

B.   When did the patient last received the medicine?

C.   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?

D.   I check to see if the medications can be changed to something different.  I review the chart to see what other medications have been used.  I check doses on all medications.  I make a list of the patient’s medical conditions.  Basically I get prepared to speak to the pharmacist.  Of course, some of this may be done while I am waiting on hold for the insurance company.

5.     Either the fax is filled out, or the insurance company is called.

6.     Calling the insurance company may involve several steps.  There is always some sort of menu of choices.  Usually there are several.  The first real person that I talk to is rarely a pharmacist.  Occasionally they can solve the problem.   Usually, I have to get transferred to someone else.

7.     When I finally get to speak to the pharmacist (usually about 15 to 20 minutes into the phone call), I need to have the patient’s name, date of birth, insurance number, Medication name, dose, frequency, condition we are treating…..  The pharmacist will then sometimes tell me WHY the medication is not being approved, or ask if we have tried other medications.  That’s why I go through the chart and make that list.

8.     We may have to change to a different medication.  Medicaid recently changed from Brand N for stomach Acid to any of three other medications.  Since they are about the same, I just changed the medicine, called the pharmacy and notified the patient.  Of course, they changed TO Brand N about two years ago, so we went through this then.

9.     Sometimes I have a form I have to fill out.  I may have to send records.  Once it was a chart that went back 15 years. 

10.   Sometimes I have to write a letter.  I have gotten mean and crotchety in my old age.  I tell the insurance company that they are assuming the risk in changing the medication because I will NOT.  I ask them for a medical license number in my state.  I state my reasons for not approving.  It’s my last effort, but it has worked when I try it. 

11.  I may get approval.  That’s my favorite.  Usually that’s because I’m prepared.  I got approval for one patient the other day until December, 2022.  I think there might have been a typo in there, though. 

12. There are two separate places in the chart where any medication interaction 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.   It makes it easy to see what medications the patient has been on all that time. 

13.  The chart is returned to Princess, who checks to make sure all of this was done.  If I forget a step, she returns the chart to me.

14.  A bill is generated. 

15. The chart is filed.

After all that, do you understand why doctors hate to hear the expression “I need to have you prior authorize my medication”?