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Drug utilization queries from insurance companies.


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A handful of times in the last year I've received mail from CVS/Caremark regarding my prescription of opioid analgesia to post-operative patients. All of it has been 100% appropriate and careful. I never give more than a 2 week supply of medicine, and my patients know that it is for acute post-operative pain only.

 

I want to know if I'm legally obligated to respond to these queries. They want confirmation that I have seen and treated the patient, that the prescriptions are truly from me, that the medications are necessary for a specific diagnosis (which I'm also supposed to supply), and when/if the patient's treatment will be re-evaluated.

 

Anyone have any idea if these are requests or orders?

 

I'm concerned that if I don't respond the patients may end up in some kind of difficulty financially, should CVS hassle them about their "possible drug over-utilization."

 

 

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I get tons of those queries and most aren't particularly helpful. Do you realize that your patient is on multiple antihypertensives? Uhhh, yessss.

 

On the other hand, every so often I learn something new and I do appreciate that. I'm not sure why we have to sign and send things back. We're buried in paperwork as it is.

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I will admit I have gotten a Beer's criteria list enclosed in some of this correspondence and it has been helpful.  For me, the real issue is when I renew a med for a patient that is not really my patient, (generally sees the doc), then my NAME is on the prescription so I am responsible.  When I  refuse to do the next refill in his stead I am called a NON-Team player.  I have offered the patient alternative drugs that will help their insomnia and discuss why high dose extended release Ambien may not be the best for them along with their other medications, including their Vicodin. 

 

We just recently have had this discussion and I don't think he or his nurse gets it.  Next convo will be about it's my license, my career, patient safety, and the idea that you don't have to keep doing what you've alway done.  Evaluating polypharmacy in the elderly should be taken into consideration every time they are in for a complaint.

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