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”?

She’s Still Mean

A woman walked into my office a few minutes ago.  She said she needed to make an appointment.  She hadn’t been seen since before she had her child.  The daughter was 23 years old.  She couldn’t get in to see her regular gynecologist in the next town.  They are booked. 

Princess started making her an appointment.  She was getting the registration papers out of the drawer.  Ms Demanding helped herself to a lollipop while she was standing at the counter.  Ms D wanted to be seen within the week. 

Princess asked what kind of insurance Ms Demanding had.

Ms Demanding said she wasn’t working.  She had an insurance that we don’t participate with. 

Princess explained that we don’t participate with that type of insurance.  She told her the price for a new appointment.  It wasn’t our highest visit, but she thought it would be a long visit from the way this woman was acting.  We have patients pay for the visit.  We will submit the insurance, but the check goes to the patient.  [I can no longer wait 6 weeks to 6 months for payments from insurance companies.]

Ms Demanding went ballistic. She said, “Well, she’s still mean, then.”  She turned around, walked out and slammed the door.

That certainly didn’t make my day, or Princess’s either.

I hope she chokes on the lollipop. 

I was so annoyed, I had trouble finding an Amazon link for you guys.  Just go get yourself a gift card for someone you like.  I think Princess deserves one.  She had to put up with this.  I just listened from my office. 

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. 

Learning from Restaurants, Part 2

Courtesy, Office Style

Refer to this post for the beginning of the series:  http://dr-lasermed.blogspot.com/2012/01/what-we-can-learn-from-restaurant.html

I have always tried to run my office with as much care and kindness as possible.  I treat my patients the way I would want to be treated.  Over the years, my staff and I have worked at finding ways to make things as comfortable and patient friendly as possible. 

We start when people schedule their visit.  My front office person (Princess) is always polite.  She goes out of her way to make sure our patients get an appointment time that is convenient.  She tries to remember if they have children that need to get on or off the bus, they work nights, etc.  New patients get asked what time is convenient, and she does everything she can to work around their schedule.  She also makes sure they know how to find the office.  Princess calls people the day before their appointment, reminds them of the time and checks to see if they need those directions again. 

If the patient is coming after having been seen in another office, we ask her to bring her records if possible.  This avoids a second visit with another fee.  This is something that most people don’t think about.  We try to be aware of cost to the patient of everything we do.  This includes the time away from work or other regular daily activities. 

We have also tried to find the best and least expensive places to have lab work and diagnostic testing.  Sometimes this is dictated by insurance.  If our patients are paying cash, price is important.  I believe this will be more common in the future.  Patients don’t think of these things, so we try to be helpful this way.

Remember, this is a gynecology office, so there are certain things that we do that are just not going to be pleasant.  I can’t help that.  But I can explain up front what is going to happen, wait for the discomfort to pass, let women lie on the table or sit in the exam room until they feel better, etc.  I also tell patients that I hate pain as much as they do.  I use anesthetics or have them take medications before procedures if possible to minimize pain.  I also talk to them while something is going on.  Many of my patients don’t realize that I have even started doing some nasty test, and it’s already done.  Over the years I have been problem solving both in and out of the exam room this way. 

I try to take a practical approach to treatments, too.  I know most of my patients are busy women.  If it’s too complicated, too expensive, or she doesn’t believe in that particular treatment she often isn’t going to finish it.  I try to pay attention to how my patients feel about different treatments, medications etc. 

We also make sure patients have follow up appointments scheduled before they leave the office, whether it is here at our office or with another doctor.  I also let them know what to expect from their medications or after a treatment.  If any testing was done, one of us calls the patient with the results, even if they are negative.  It’s important to follow through. 

There are some issues with these policies.  That will be part three in the series!

Phone Etiquette -3- Voice Mail

I really don’t understand this one.  Perhaps someone who is a couple of decades younger than I am can explain it to me.  Leave something in the comments if you can!

We ask our patients to leave us a number that we can call.  This number is to give them lab results, remind them of appointments, call them if we have to reschedule or for any other reason that we need to contact them.  Often this will go to “voice mail”. 

Personally, I’m not fond of voice mail.  I leave messages, but tend to get confused when talking to machines.  I know you young folks are better at it than I am.  However …..every message we left the day before Thanksgiving for the Monday after Thanksgiving was lost or “not received”.  Every single patient called about their appointment.  Princess called every patient on the schedule. 

Excuses included “my phone was turned off”, “my kids use the phone and delete my messages”, and a couple of other things.  They also had appointment cards from their previous appointments.  We were accused of not calling.  We were closed on Friday.  So were most of the rest of the business world except the retail stores.   Our patients know we don’t do “robo-calls”.

I just don’t get it.

She Wants What?

Princess reported the following phone conversation:

Mrs. Wantsitall:  I need to cancel the appointment for my daughter this afternoon.

(This is less than 24 hours notice – we charge for this)

Princess:  Why would that be?

Mrs. Wantsitall:  The kids were approved for insurance you don’t take last week, so she is going someplace else.

Princess:  OK.  Are you keeping your appointment?

Mrs. Wantsitall:  Yes, but I don’t want my Pap smear today because I’m feeling sort of crampy.

Mrs. Wantsitall:  By the way, can the doctor write a letter for Teenage Wantsitall for school to break the rules because she wants to, and have it done by 1:00 PM today when I come in for my appointment?

Princess said she would check. 

Note that she has been getting samples of her birth control pills from us when she doesn’t have the insurance we don’t take because we understand about Mom’s financial issues. 

This is what we as doctors have to deal with on a daily basis.  :-(

Medical Office Quandaries - 4

Missed Appointments

I’m sitting here staring at the walls at the moment because a patient didn’t bother to show up for her visit that was booked for an hour.  Ms Noshow also didn’t bother to cancel.  Princess called her twice yesterday and again this morning to remind her that she had an appointment.  The current phone number went to voice mail. 

She has been a patient for a little over a year.  I have at least 5 different phone numbers in her chart.  There are multiple notes in this patient’s chart about leaving messages, phone not being turned on, and her phone not being in service.  It helps to write this down, so Ms Noshow can’t say we didn’t try.

PEOPLE!  What happened to common courtesy?  It doesn’t matter whether it’s a 5 minute visit or a 2 hour visit – that time was reserved for you.  If you’re not coming, you should call.  It has gotten to be so common for people to forget that most offices call one or two days in advance to remind people. 

Several years ago, I finally instituted a charge for this.  Princess and I agree that wasting our time needs to be paid for.  Some people don’t pay the charge.  We don’t see them ever again.  Sigh.

If you PROVOKE PRINCESS 3

If you PROVOKE PRINCESS

Here’s your POTENTIAL PENALTY *

What we want to charge patients for:

Rescheduling referrals and tests: $25

Princess spent a lot of time scheduling those tests.  Sometimes I had to call to get a doctor to see you before their front office wanted to fit you in.  If you need to reschedule, call the office or hospital and take it up with them.  Please don’t put us in the middle.  You will then find out how hard it is to manipulate someone else’s schedule.

*This is a recurring feature. Princess and I get certain patterns of phone calls that we find annoying. We would like to present them to you, with what we would like to charge for them. Unfortunately, we can’t. Charge that is. The phone calls will remain annoying. Princess says she could get rich if she could charge for all this stuff.

Electronic Medical Record Rant 3

Barriers to Care

Doctors are speaking out more and more about electronic
medical records.  As a general rule, we’re not really fond of them.  There are lots of different reasons:

·        Some of us don’t type all that well.  It’s just a fact of life that your average 60 year old doesn’t touch type at 70 to 80 words per minute.  This is one time I’m glad I’m “above average”.

·        Many of the EMRs have a touch screen that you have to pick various places and go from screen to screen to enter data.  They were not designed by the people who are actually using them.

·        I feel that it puts a barrier between me and my patient.  Before, when I was talking to my patient, I would lean on the chart, making small notes if needed, and fleshing them out later.  Now I sit behind a laptop and type off and on the whole time I am talking to the patient.  It feels impersonal.

·        My EMR won’t print out the bill until the note is complete.  So, I have to have the note finished before the patient leaves if she wants a receipt.

·        Perhaps we are mistaken about this process.  There are NO written instructions, just a very confusing web site.  We get referred there with questions.  Tech support isn’t very helpful with the little things. 

·        Remember, I’m a dinosaur.  Chat rooms just don’t cut it for me.  My 17 year old kids have given up on helping me with this, too.  Princess knows less than I do about computers. 

·        I have paper charts that go back literally 27 years.  There is NO way I can enter all that data into the computer.  Nor do I want to.  I usually start with: “This patient has been seen since 1987.  She has an extensive paper chart that will NOT be summarized here….”

·        I started a medication flow sheet in 1995.  When someone asks for “that medicine that you gave me that worked for….” I just flip through the sheets until I find it.  Not going to enter these, either.  I think they have fixed the program so it will enter from now on.  I’m not sure.  The update was just last week. 

AAAARRRRGGGGHHHH!!!!!

If you PROVOKE PRINCESS 2

If you PROVOKE PRINCESS

Here’s your POTENTIAL PENALTY *

What we want to charge patients for:

Inquiring about your appointment time after the first $5.00

Please keep those little appointment cards we give you.  Or write the appointment down somewhere. 

*I’d like to make this a recurring feature. Princess and I get certain patterns of phone calls that we find annoying. We would like to present them to you, with what we would like to charge for them. Unfortunately, we can’t. Charge that is. The phone calls will remain annoying. Princess says she could get rich if she could charge for all this stuff.

If you PROVOKE PRINCESS

If you PROVOKE PRINCESS

Here’s your POTENTIAL PENALTY *

What we want to charge patients for:

Changing your appointment time:

First time: $5

Second time: $10

Each additional: $15

*I’d like to make this a recurring feature.  Princess and I get certain patterns of phone calls that we find annoying.  We would like to present them to you, with what we would like to charge for them.  Unfortunately, we can’t.  Charge that is.  The phone calls will remain annoying.  Princess says she could get rich if she could charge for all this stuff.

Another Office Conundrum

Princess calls all our patients the day before their appointments to remind them about their appointment.  It is very common for doctor’s offices to do this.  Why, you ask?  Because people forget that they made the appointment.  They don’t come to the office.  We sit around looking at each other.  Other patients who could have come in for appointments can’t come in.  Besides, it costs us money every time someone doesn’t come in.  That raises the price for everyone else. 

What happens when Princess calls? 

Her favorite thing is to talk to the person who made the appointment.  They confirm it.  Everyone is happy.  This is a rarity.  Her next favorite is to get the machine and leave a message.  This is more common.

I hear a lot of grumbling about numbers that are “not in service”.  Another complaint Princess makes often is that mailboxes are full.  We have people that won’t answer their phones at all.  We have people that answer the phone and say they have no idea who that person is. (????)

My personal favorite is when Princess calls someone and they deny ever having made the appointment.  Princess is the only one that makes appointments.  So she KNOWS that the person made it.  She won’t let anyone but the patient make an appointment.  She knows it wasn’t the mom or the husband.  I don’t treat Alzheimer’s patients. 

Several years ago I instituted a “missed appointment fee”.  If you don’t show up, there’s a charge.  This covers part of the time we waste when you aren’t here.  It’s also a stimulus to keep your visit.  I think that’s why people say they have no idea what Princess is talking about.  

Yeah, right! 

You can’t be seen until you pay that fee.  Most patients have no intention of ever paying it.  I’m so sorry.  That’s how I get rid of patients who are unreliable.  My cardiologist told me I need less stress.  This helps me, but I’m a little worried about Princess’s blood pressure.