jmj11 Posted December 16, 2014 Share Posted December 16, 2014 I don't know if other people have noticed, but the "Apple Plans" (commercialization of Medicaid) have become beyond belief in their rejection of prescriptions, asking for prior auths for everything. As you know, each prior auth requires me to take 15-20 minutes to review the patient's entire history and to document everything that they have tried and failed. The problem is, this use to only be for the branded, more expensive medications. But now I get 10-20 per day for non-branded simple meds. Here is a list of prior auths that have come to my desk today: sumatriptan PO 100 MG amitriptyline 10 MG tablets propranolol 20 MG tablets indomethacin 25 MG capsules. This is totally out of hand. Right now I spend 2 hours a day just on prior auths. We have stopped accepting new apple plan members, part of it because of this and part of it because they pay so poorly. So my question is for you, do you have any strategies for dealing with this? I told my office manager that we will not do any more of these simple generic prior auths. She says that if we don't we will loose even more time with angry patients tying up the phones and demanding to have it out with us? There must be a strategy that someone has found to work. Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 16, 2014 Moderator Share Posted December 16, 2014 I am charging $10-25 per form to be filled out - for any form..... On that the patients demanded I fill out at that moment on a weekend was $40 (and should have been much more to take time away from my family) Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 16, 2014 Share Posted December 16, 2014 Advise the patient the insurance requires paperwork and you need to schedule an appointment for follow up. Maybe you are being too careful/thorough with these forms ? Link to comment Share on other sites More sharing options...
jdenning Posted December 16, 2014 Share Posted December 16, 2014 We are getting prior auth requests for everything now - even generics which is ridiculous. There is no reason in the world amitriptyline 10 mg should require a prior auth. We are trying to make patients make appointments for forms - FMLA or whatever. I spent over 30 minutes the other day talking to 3 different insurance people about why a patient needs brand name tegretol. My explanation AS THE PROVIDER was apparently not good enough - they wanted to review chart notes! It turns out that it's covered but the co pay is of course higher than generic and needed some kind of "peer to peer" to reduce the co pay. Absolutely ridiculous Link to comment Share on other sites More sharing options...
winterallsummer Posted December 16, 2014 Share Posted December 16, 2014 Unfortunately the trend in health insurance is to put up even more barriers so people put off going to the doctor. This is fine when keeping URIs out of the ED but many new plans are not even having decent coverage for office visits besides an annual well visit. Prior autos, higher copays, unfair deductibles - all are increasing and the message being sent is avoid getting health care and don't take your medicine. While this may deter some unneeded visits, unfortunately it is going to also encourage people to not go to the doc or PA unless they're absolutely dying. At the same time hospitals are being punished for re admitting people who need admissions. It feels we are turning our back on the sickest in order to try to save money. But if primary care and close f/u with appropriate specialists is discouraged, the end result is going to be sicker patients. Link to comment Share on other sites More sharing options...
wilso2ar Posted December 16, 2014 Share Posted December 16, 2014 Our MAs/RNs have gotten really good at collecting data for PAs and know what most of the plans require for step therapy. Although your prescribing is a little more complex than ours I'm sure. What the heck are you supposed to use before amitriptyline? Link to comment Share on other sites More sharing options...
jmj11 Posted December 16, 2014 Author Share Posted December 16, 2014 I've noticed this change over just the past 2-3 months that even what was considered tier 1 meds are being rejected by the commercial medicaid plans. I will have to put an end to this but it will create a huge amount of animosity and I honestly believe this is what the insurance companies intended. Paying for nothing and then blaming the provider for not filling out the prior auth forms. Link to comment Share on other sites More sharing options...
wilso2ar Posted December 16, 2014 Share Posted December 16, 2014 I think you are right. We do prior auths all the time for injections and advanced imaging as well as medications. They always get approved, but it is just one more hoop we need to jump through to get a patient treatment. The insurance companies are hoping that we will not do the necessary paper work to save them money on treatments that patients need. Link to comment Share on other sites More sharing options...
BruceBanner Posted December 16, 2014 Share Posted December 16, 2014 I work in VA compensation and disability and the BS is just as deep. For a rateable condition there has to be objective evidence; which sounds fine on paper but what it translates to is that the providers assessment and medical opinion is never good enough. "Think he has X condition because of agent orange exposure? Well we haven't conceded he was actually exposed, so form another opinion." I think the war between providers and insurance companies will eventually reach a critical mass, making independent practices unsustainable unless they follow a concierge model. Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 16, 2014 Share Posted December 16, 2014 that is ridiculous Link to comment Share on other sites More sharing options...
Guest Paula Posted December 17, 2014 Share Posted December 17, 2014 Welcome to the expansion of government funded health care. It will get worse. Link to comment Share on other sites More sharing options...
Guest JMPA Posted December 17, 2014 Share Posted December 17, 2014 Do the wealthy get effected by this? Link to comment Share on other sites More sharing options...
bobuddy Posted December 17, 2014 Share Posted December 17, 2014 Prior auth today - new type II diabetic. I prescribed metformin. Denied. Prior auth required. I have no words.... Link to comment Share on other sites More sharing options...
UGoLong Posted December 17, 2014 Share Posted December 17, 2014 This is not because of "government funded healthcare," much as some people might want to make everything the government's fault. Without healthcare, lots of these people we dedicate our lives to treating would be ....dead. By the way, we ARE the government (or at least we enable its behavior with our voting patterns). I think that the blossoming of prior auths is because insurance companies are trying to cut premium increases and make more money by saving the cost of some therapies. Some of this makes sense and other aspects don't. Today I spent 90 minutes I didn't have trying to get Tekturna renewed for a patient who was already on 4 generic antihypertensives and has an SBP of 180 without Tekturna. It was 130-140 on those four plus Tekturna for several months, until his plan changed. I finally found a helpful person at Caremark who told me what to put into a letter of medical necessity requesting an urgent review. I gave the patient our last two weeks of samples and sent him on his hopefully stroke-free way. (And yes, we've already done a renal workup and serum metanephrines.) I don't expect insurance companies to pay for anything we want to do, but some balance would be deeply appreciated. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted December 17, 2014 Administrator Share Posted December 17, 2014 For amitriptyline for a headache, or Metformin for a Type II diabetic, I would complain to the state insurance commissioner. Those are standard of care, period, and the prior auth request is objectively unreasonable. For good measure, get the name and license number of the medical director, and report him or her to the state medical board. Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 17, 2014 Moderator Share Posted December 17, 2014 Prior auth today - new type II diabetic. I prescribed metformin. Denied. Prior auth required. I have no words.... WHAT??????????? Link to comment Share on other sites More sharing options...
jmj11 Posted December 17, 2014 Author Share Posted December 17, 2014 Here is a form letter that I'm sending to each insurance that ask for a prior auth on an old, cheap, generic medication: Link to comment Share on other sites More sharing options...
primadonna22274 Posted December 17, 2014 Share Posted December 17, 2014 That is a work of beauty Mike. I haven't yet seen any of these ridiculous denials myself here in SC, but I'm sure they are coming and with your help I will be ready! Link to comment Share on other sites More sharing options...
jmj11 Posted December 17, 2014 Author Share Posted December 17, 2014 This started her about two months ago. I got a refusal from Molina for generic indomethacin. I wrote them a letter asking them what do I then use for my "Indomethacin-responsive-headache-disorder" patients, who by definition only respond to indomethacin. They didn't know what those headaches are and had never heard of them . . . then recommended hydrocodone or gabapentin but still refused indomethacin. Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 17, 2014 Moderator Share Posted December 17, 2014 Here is a form letter that I'm sending to each insurance that ask for a prior auth on an old, cheap, generic medication: GREAT letter love the last paragraph that you give a copy to the patient as well Link to comment Share on other sites More sharing options...
Guest Paula Posted December 18, 2014 Share Posted December 18, 2014 From my perspective this issue is related to government run health care and the ACA. Part of the ACA was the insurance companies and pharmaceutical companies getting special deals if they participated. Back room deals ensued and the patient suffered at the hands of the government, insurance companies and pharmaceutical companies. They are all in it together to cut costs at the expense of the patient's health. A three- some, if you will. None of them really care. They just pretend to care. And shift blame to those of us who truly care about providing top notch medicine. I agree with sending a complaint to the insurance commissioner. I project some of our patients will end up dead even with ACA insurance that denies medications. They won't be able to pay for the deductibles and co-insurance, some companies offer no drug coverage until meeting the $5,000 deductibles. Link to comment Share on other sites More sharing options...
UGoLong Posted December 18, 2014 Share Posted December 18, 2014 Paula, What you recount may very well be be the case, but without what we have now, those people wouldn't have any healthcare coverage at all. The challenge is to make ACA better, not to go back and let people try to live without it. Link to comment Share on other sites More sharing options...
PACdan Posted December 18, 2014 Share Posted December 18, 2014 There should be no such thing as for profit health insurance companies in this country. I feel the same way about hospital systems as well. Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 18, 2014 Moderator Share Posted December 18, 2014 There should be no such thing as for profit health insurance companies in this country. I feel the same way about hospital systems as well. BINGOOOOOOOOOOOOOOOOOOOOOOOOO Link to comment Share on other sites More sharing options...
winterallsummer Posted December 18, 2014 Share Posted December 18, 2014 I pay for my own insurance. I pay twice what I used to pay now (my plan was cancelled as not aca compatible) and my coverage is a joke. I thank God I am in good health because if I had half the med list and specialist visits of my average patient, I would not be able to take care of my health even on a PA salary. Overall I have tried to support aca as a "health care for all" but I am getting frustrated as myself and my patients are paying more for new plans with awful coverage. Even rxing all generics and PTs seeing only absolutely needed specialists and otherwise managed by fm and still these PTs cannot afford their care. I am hoping the big picture aca will work out because I do want everyone to get insurance. I am just disheartened by the fact that so many of the plans so bad. Link to comment Share on other sites More sharing options...
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