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”?

Definition of “Old” or “Older”

It finally happened.  I am now officially “older”.

I went to a new dentist yesterday because my dentist of over twenty years has retired.  That’s probably my first clue.  I saw the younger partner.   She’s the daughter of the older partner.  After my cleaning, she was telling me that my problem was like that of many of her “older patients”. 

I know she does most of the children in the practice.  I switched because she has been so patient with Mr. Impatient (my autistic son).  We switched him to this practice after he got scared about something at our established practice and refused to go back.  He originally saw “Papa” dentist, but has bonded with “Daughter” dentist.  We even went through her last pregnancy with her.  Mr. Impatient got concerned when we had to reschedule because she was off on maternity leave. 

Anyway….I have had this discussion with patients and other physicians in the past.  I also have had it with insurance companies when talking about hormone replacement therapy.  How old is “old”?  How old is “older”?

My personal opinion is that “older” is at least ten years older than you are.  Probably more like twenty.  I think “old” is ten to twenty years older than your parents. 

Since I am of “daughter dentist’s” father’s generation, I’ll take older.  It’s OK even if my kids are only a few years older than hers.  I started late. 

Giving doctors your credit card before an appointment

Giving doctors your credit card before an appointment

Many physicians’ offices have started a new practice – asking for a credit card deposit before scheduling an appointment.  This is much more common for new appointments, but you may also see this with repeat appointments.  Some just ask for the number, some actually charge a deposit.  Why? 

There are several reasons.  This is an incentive for patients to actually keep their visits.  We have a remarkable number of “no shows”.  In some offices, for new patients, this can be as much as 75%.  This time is reserved for the particular patient, and we can’t fill it with someone else.  We still have to pay our staff and overhead.  So we lose money if you don’t show up.

It’s interesting that we don’t even blink when we are asked to give that same credit card for a car reservation, a hotel room, or even a table at a restaurant.  But putting a deposit down at a doctor’s office?  It’s like we actually have to pay for health care!

That’s the issue.  We have become so disconnected from paying for our medical care.  “Bill my insurance” is commonly heard in every front office.  Patients have no idea about deductibles and co-pays.  They also have no idea what it costs to wait for their insurance to pay and bill for the difference whenever we finally hear from the insurance.  Often patients don’t pay at that point. 

New fees

It’s a good idea to ask about cancellation policies when making your appointment.   Insurance companies don’t pay those fees.  Every office has different policies.  Some practices waive a fee if illness keeps you from turning up.  Some offices will give you written policies.

Some medical practices have introduced other fees in the past few years for things that were previously free or for which a patient might not expect to pay.  A physician’s office in New Mexico charges a $10 fee to rewrite prescriptions for controlled substances, which expire seven days after first issued.  A family practice physician charges his patients a per-visit malpractice insurance surcharge.  Other surcharges reported among family physicians include a charge for referring patients to specialists and for a prescription or refill not attached to an office visit.  You will also start to see fees for paperwork like FMLA, physical forms, pre-authorizations, insurance issues, etc. 

You may try reading your doctor’s Web site carefully to see if things that were once free now come with a price.  You can also ask when you schedule your appointment or when you come in for your visit.  Doctors are charging for more of these types of things because they are becoming much more time consuming without payment.  Insurance companies and patients are also paying less and less for each visit.  We have to spend our time or our staff’s time (or both) doing so many of these things. 

See future post: Example of “Just a Medication Refill”

“Uncompensated” Medical Care - Charity

Back in the old days, doctors used to do a certain amount of what they called “charity care”.  They would care for people who were truly poor.  They knew that they were not going to get paid in cash.

Sometimes a church, a school or some other organization would raise money to help pay some of the costs of that care.  People paid what they could.  They paid in chickens or pigs or apple pies.  If you couldn’t pay with money, you might come by and mow the doctor’s lawn or do some other work that needed to be done. 

Martha who kept the doc’s books would kind of figure out when your bill was paid.  Everyone (except possibly the IRS) was happy.

Sometime after WWII, employers started offering “health insurance” instead of increasing employee’s wages.  Doctors didn’t mind, because they got paid what they charged in real money. 

Then Washington decided that the government needed to get into the insurance business.  Medicare and Medicaid were born.  The government decided that it was not going to pay the whole bill.  Instead they would pay what they wanted to pay. 

More and more people qualified for these programs.  As the cost of the programs went up, what the government paid went down.  Doctors at first made up for this by working harder, and by charging other patients more. 

Insurance companies decided they didn’t want to pay the whole bill either.  They started to demand the same discounts as Medicare.  Doctors worked harder.   Patients got less time for each visit.  Our hours got longer.  Your waits got longer. 

Medicare and insurance companies developed more rules and regulations like prior authorizations, formularies, preferred providers and ICD and CPT codes.  Did that sound like a bunch of garbage to you?  Until I started “doctoring” it did to me, too.  They didn’t teach you all that stuff in medical school when I went, either.

Doctors had to hire people just to do the billing and “chase down the payments”.  Then they weren’t payments, they became “reimbursements”.  “Patients” became “Insureds” and office visits and surgeries became “claims” and “procedures”.  Insurance companies started “bundling” all your care.  Surgeons get paid the same no matter how many times they see you in the three months around your surgery.  OB doctors get paid the same for the entire pregnancy and 6 weeks afterwards.  It doesn’t matter how many times they see you in the office or the hospital.  The only thing that increases the fee is a cesarean section.  Some insurance companies won’t pay extra for that. 

There isn’t enough room here to discuss what happened when the lawyers got their fingers in the mixture.  Besides, my doctor wants me to watch my blood pressure.  Let’s just say that a lot more testing goes on these days to keep from being sued.  It costs lots of money and doesn’t add much to the answers we get.  Lots of paperwork ensues. 

Patients – pay attention here – that’s you! – are now so far removed from what things cost that they don’t care about what tests are done.  They want the CT scan or the MRI.  They want all the blood work, all the nuclear medicine testing, and all the consultants.  The insurance is paying for it after all.

Not really.  If you have private insurance, your premium goes up if you keep getting tests.  If you have “public insurance” the taxpayers pay for it.  Either way, it’s busting our system. 

Ask people who don’t have any insurance.  I have lots of them in my practice.  You see, I don’t take insurance any more.  I have gone from 4 employees to 1.  We will give you the papers to submit your insurance, but we won’t fight it for you.  That saves us hours on the phone.  I don’t participate in Medicare and Medicaid.  I don’t have to take those huge discounts.  So I get paid for my time. 

I get to spend more time with my patients.  My overhead is a whole lot less.  So I don’t have to charge for all those people that used to work here.  We have time to help figure out where the least expensive place for an MRI is and help our patients find other doctors to help them.  I also found a lab that gives discounts for cash.  We also decide what tests we really need, not what insurance will pay for. 

This is what I went into medicine for. 

Here’s another blog with another version of this:

http://roadtohellth.com/2011/11/why-does-the-cost-of-healthcare-keep-going-up/

Health Insurance 101-5 “Adjustments”

When an insurance company uses the word “adjustment”, they mean the discount they have “negotiated” (dictated) with your “provider” (doctor, pharmacy, hospital, nursing home…..).  This is the amount of the charge that they are not going to pay.  If the “provider” is “participating”, they cannot collect this money from you.  If they do not participate, they can collect this money from you. 

Generally speaking, the doctor had nothing to say about how much the discount was.  If the group is large enough, or if they are the only group in town, they can cut down the discount a bit.  If the insurance company is powerful enough (think Medicare), this is not possible.

I am your Doctor, not your Mother

The Directions are on the Bottle

I had a patient in the office that I see frequently for chronic pain.  One of her prescriptions has to be written every month.  There are many medications like this.  It is a controlled substance.  It is dangerous to take too much of this medicine.  

You get 30 days of pills and it needs to last 30 days.   This patient had filled her prescription 20 days ago and had ½ pill left.   Here we go again.  I sighed. 

“Have you been taking more of the medication than what you were supposed to?” I guessed (hoping that she had not been selling her pills).

“I’m having pain in the middle of the night, so I get up and take more of the stronger pills.”   She has a prescription for other medication for pain, but is almost out of that, also.   She didn’t call the office to report problems. 

This patient and I had this problem before.  Her insurance will not pay for more pills.  She cannot afford the ten days of medication.  It costs as much as a house payment. 

I felt like I was reprimanding a three year old child.  “This is the last time we can have this conversation.  If you can’t follow the rules, you’ll have to find another doctor.”

Basically, I can’t be your Mommy.  You need to grow up and follow the directions.  Can you spell W-I-T-H-D-R-A-W-L?

Health Insurance 101-4

Deductible and Co-Payment

This is something that many people do not understand.  It should be relatively simple.  For the millionth time (big sigh here):

Deductible:

This is the amount that you have to pay “out of pocket” (they mean your money) before the insurance company is going to pay anything. 

Remember your previous lessons:

The Insurance Company has already determined what is Usual and Customary (101-1).  This may not be what the doctor charges.  Your doctor may not be a “participating provider” (101-2).  In this case he or she can charge more than what the insurance company “allows”.  And if the doctor does not participate with the insurance company, they will reimburse you (101-3).

Are you keeping up and studying? 

OK, who is responsible for paying the deductible? 

If you said the insurance holder (i.e. you) you passed the pop quiz and may progress to the next part of the course.  

You are also responsible for knowing how much it is, and how much of it you have paid.  Otherwise the office will collect either what your card says is the deductible, or the entire bill and then refund whatever they get from the insurance company.   

Co-Pay:

This is how much you have to pay every time you have an “encounter”.  It may be:

·        A percentage of the charge

·        A percentage of the usual and customary

·        A fixed amount

·        The difference between the percentage of usual and customary that your insurance company is going to pay and the total charge (if the doctor does not participate)

You must pay your deductible first.

It’s About Time!

Now You Can Monitor Insurance Rate Hikes

Now you can monitor any insurance company’s rate hikes, as well as the reason for doing so.  This article in USA Today explains that there has been a 9% hike in the average price of health insurance this year!  Earnings per share are 46% over estimates!

The web site to check is http://companyprofiles.healthcare.gov/.  The article is:

  http://www.usatoday.com/money/perfi/insurance/story/2011-10-07/health-insurance-rate-hike-website/50682044/1

Health Insurance 101-3 Reimbursement

Reimbursement is a fancy term that insurance companies made up for payment.  The dictionary defines this as

1.     To make repayment to for expense or loss incurred

2.     To pay back; refund; repay,

Reimburse is also defined as: to repay or compensate (someone) for (money already spent, losses, damages, etc)

Technically, the money is supposed to already be paid.  The insurance company is supposed to be paying their insured back a portion of what they have paid out to the doctor, hospital, contractor, electrician or whomever. 

If your doctor is having trouble collecting the money, he or she may ask you to pay the bill and negotiate with your insurance company.  If your doctor does not participate with the insurance company (see this http://dr-lasermed.blogspot.com/2011/09/health-insurance-101-2-participating.html ), you may very well get the check. 

Your doctor’s office will often know what the insurance company is going to do.  If they tell you that you are responsible for the bill, don’t argue.  They know what they are talking about. 

(Italics mine as is sarcasm.)

Health Insurance 101-2 “Participating Provider”

There are two parts to this one.  The first is “participating”.  This means that the insurance company has a contract with someone or something.  The insurance company has agreed to pay directly to this “provider” in a “prompt” fashion.  In return, the “provider” agrees to give the insurance company a significant discount on the charges.

Basically, the insurance company threatens otherwise to wait forever and/ or pay the patient for the service.  Then the “provider” has to try to get the money from the patient.  However, many patients think that the check from the insurance company is money for them to spend.  This is especially true if it is a large amount of money.  The “provider” may be taking payments for years.  The “provider” benefits by getting the check directly from the insurance company. 

We all know that it is corporate blackmail, but nobody can actually prove it.  The insurance company will say that they trust their clients to bring the check directly to the “provider”, and the “provider” must take that risk if they don’t want to “participate”. 

The second part of the statement is “Provider”.  What is a “Provider”?  In health care talk, this can be a pharmacy, a hospital, a home health agency, a chiropractor, an optometrist, a physical therapist, a nurse practitioner, a physician’s assistant, a nursing home……. and maybe a physician.  I didn’t spend eight years in training after college to be lumped with all of these other “entities”. 

Health Insurance 101 - 1 "Usual and Customary"

I find there are a lot of terms that insurance companies use that are confusing to consumers.  As someone who has been dealing with them for many years, let me give you the doctor’s version of some of them.  I look forward to your comments.

“Usual and Customary Rate” is what the insurance company decides it wants to pay.  It has nothing to do with what the doctors in the area charge or expect to get paid.  Of course they represent to the patient that the doctor is charging more than s/he should.  Insurance companies also tell patients that they are not responsible for any more than what the insurance company determines is the UCR.  This may be true if the doctor participates with the insurance.  If the doctor is not a “participating provider” (Health Insurance 101-2) you are responsible for whatever the insurance doesn’t pay.   

Insurance companies are not allowed to set a doctor’s charges.  They can tell us how much they are willing to pay.  We can decide whether or not we are willing to work for that amount of money.  If not, we don’t participate. 

Prior Authorizations 1

You Need Permission for This Medication Why?

Prior authorizations are one of my least favorite things to do.  Most other physicians will agree with me.  When I first started in medicine – back when dinosaurs roamed the earth – we didn’t have to do this.  Now, almost any time I write a prescription or order a test, it seems like someone is second guessing my clinical judgment.  Actually, they are.  And I, as a board certified physician, resent it.  It also takes an immense amount of time.  Patients and insurance companies do not feel the need to pay me or any other doctors for our time.

From personal experience, here are a few of what I consider to be wasteful or ridiculous prior authorizations.  OK, I will break my rule and use the “S” word.  Most of these are just plain STUPID.  You be the judge.  I’ll be anticipating your comments.

I have one insurance company that requires a prior authorization for birth control pills for EVERY patient under the age of 18.  They must NOT be prescribed for birth control.  Of course we in GYN use them for many other things, but isn’t it a nice side effect that your 16 year old isn’t getting pregnant?  I have to call once a year to authorize these.  Sometimes even if the woman is over 18.

I have another patient who is in her 30s.  She is autistic.  She is on Depo-provera to control her periods.  Since she has NEVER been sexually active, this is NOT for birth control.  The insurance company requires that I call them yearly.

Imitrex is a medication that is used for migraines.  It comes in pills, nasal spray and injections.  I have one patient who can ONLY get relief with the injections.  Her insurance company has this on the approved list, but I have to call them to authorize it and tell them that she HAS tried other medications.

I have another patient with fibromyalgia who is having difficulty adjusting the dose of a particular medication.  Every time I change the dose, I have to call Medicaid.  EVERY TIME.

My favorite story is a lovely patient I have who is in her 80s.  Sometime in the mid 1990s I put her on a particular estrogen vaginal treatment.  We tried several cheaper methods, but she had allergic reactions.  She has been on this medicine since that time.  About 5 years ago, her insurance decided they would no longer pay for the little estrogen tablet.  I spoke with the pharmacist.  I had to fax the entire chart.  For the last 15 years.  We finally got things approved.

Two years later, she switched pharmacy benefits plans again.  This time the pharmacy decided that we should try an estrogen patch.  We fought back and forth for FIVE DAYS.  I finally had to threaten the pharmacy benefits plan with “practicing medicine without a license”.  I also told them that her cardiologist and I were not willing to take the risk of giving her systemic estrogen.  If they wanted to assume the medico-legal risk of doing so, and do it in writing, I would be happy to let them. 

We got our approval.

Say what?

You never know what your insurance company is going to do.  This is a story from Australia about a man who was supposed to schedule for hand surgery and......
http://www.theage.com.au/victoria/congratulations-sir-youre-pregnant-20110819-1j19p.html

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