Prior Auths . . . A Strategy

[jmj11]

Unless you are really insulated from the insurance side of things, most of you will recognize that it is becoming more and more time-consuming for prior auths.  This is anything from the complex procedures down to generic medications.  Yesterday, my office manager was on the phone for almost 2 hours with an insurance company (most of that time on hold) to get zolmatriptan approved. It worked slightly better than the formulary choices. I paid my office manager $50 for her time (salary).

 

The insurance companies expect this time to be for free. But it is really getting out of control.

 

Right now, I do not fill out forms (FMLA, leave etc.) unless it is during a billable appointment.  Most insurance companies will not pay for form completion and while we charge patients for this, most pay very little.  So, if we see them for a follow up and then fill the forms, we are giving them care, but we are no longer giving them care for free.

 

Now it comes back to prior auths.  I'm considering that each time I order a procedure, or a medication and the insurance rejects it and ask for a prior auth, that rather than giving away 1 hour to 90 minutes per day of my time (which I do now) for free, that I reschedule the patient. Then we sit down together as a visit and the patient and I get on the phone and fight with their insurance company together. Because this is at the center of good care (getting the procedure or medication) then I would consider it a legitimate visit. Then we bill for that time, after documenting clearly what we were doing.  

 

I don't know of any lawyer that spends 1-2 hours per day doing work for  their client for free.

 

Any thoughts?  But I think we we don't do something this is going to get worse and worse.

[Acebecker]

Our office is in the same boat.  For now, what I do is switch them to a different medicine or give them nothing if I was purely trying to treat a bothersome but self-limited symptom (reactive airway disease, for example, in the setting of a URI).  If it is something the patient is passionate about, we'll give them the information and let them make the prior auth phone call, depending on the situation. 

 

What I think we have come up with is charging a flat, out-of-pocket fee for filling out a form.  If it's more than "x" number of pages, the fee doubles or is pro-rated per page.  Other providers in the office will do precisely what you've done. 

[SocialMedicine]

the problem I find is we spend time and the PA gets denies because all along the insurance company had a preferred drug. So all of that effort is wasted then I would have initially prescribed the preferred agent.  Inhalers/Asthma are a perfect example.

[cbrsmurf]

I guess it's a better idea than throwing myself on the floor and having a temper tantrum

[ventana]

I used to fight the drug PAs....  now I just ask what is covered

 

as for imaging PAs I tend to get more feisty....  I once had a retired pathologist tell me that he would not approve the LS spine MRI because the patient had not had pain long enough.... I could literally stick a pin in his L3 Dermatome with out pain.....  Needless to say after not so nicely asking when the last time he examined a living patient was, and what his medical license number was so that I could document which PHYSICIAN was denying this urgent MRI he agreed it was covered.....  

 

 

I simply don't have time to argue with the insurance companies most the time - i also don't believe that the "name brands" really work any better then the cheap generics so I rarely write a name brand.  As for patient preference - I tell them that they have a contract with the insurance company and if they wish to ignore it then they have to pay for the med.....  

 

I make the insurance company the evil one, and on the really tough patients - I tell them to complain to the insurance commissioner in my state......

 

 

 

Disclaimer - I no longer get many PAs as I am a single payer practice (Medicare) so pretty straight forward.....  

[jmj11]

By the time they get to me, all covered drugs have been tried. So prior auths are a way of daily life.

[cupojava]

I'v found that faxing them prior auth fax form works faster in most cases.  It keeps the staff of the phone at least.  Once, I faxed them a 53-page endocrinology guideline as evidence to use insulin to treat newly-diagnosed DM pt with A1c of >10.  Was initially denied because pt was not on Metformin previously. Annoying.  I can imagine you have to deal with them more often since you are specialty care.

[Acebecker]

I had a physician working with an insurance company try to tell me that a patient with pleuritic pain in the mid back, with recent travel, borderline tachycardia and an elevated d-dimer would not be covered for an urgent CT angiogram because she had had a CT ordered by another doc a month prior (hadn't had it done yet) for monitoring of malignancy.  Also, he informed me that in the outpatient setting I should not work up PEs. 

 

I almost hung up on him.  In the end her insurance did deny it but the CT tech did it anyway because he knew she needed it done. 

 

Insurance companies are frustrating. 

[jmj11]

I had a physician working with an insurance company try to tell me that a patient with pleuritic pain in the mid back, with recent travel, borderline tachycardia and an elevated d-dimer would not be covered for an urgent CT angiogram because she had had a CT ordered by another doc a month prior (hadn't had it done yet) for monitoring of malignancy.  Also, he informed me that in the outpatient setting I should not work up PEs. 

 

I almost hung up on him.  In the end her insurance did deny it but the CT tech did it anyway because he knew she needed it done. 

 

Insurance companies are frustrating. 

 

 

The last time, when something like this happened to me, the insurance radiologist told me I couldn't do the scan I asked her for her full name and phone number. She asked why. It told her that I will document very carefully who was responsible for not getting the scan so the patient's family would know who to sue if there is a bad outcome. She said that I couldn't do that. I said I am doing it.  She then said that she wasn't telling me not to do it . . . but only that they wouldn't pay for it if I did.  She eventually did approve it.

[jdenning]

I prescribe all kinds of medications that aren't on anyone's formularies so I deal with this a lot. Usually I get a call from the patient saying that the insurance wouldn't cover the medication I prescribed. I then have staff call the pharmacy to ask for a PA, and some days later it will be on my desk. I don't understand what's wrong with so many pharmacies that they don't help to expedite the process - it's usually us calling them. Our EMR is set up with a section to document all the meds etc that have been tried before and the outcome/side effects etc so at least it makes doing the form a little quicker. Then some number of days later I get a yay or nay from the insurer. In the meantime the patient has gone well over a week or even 2 without the medication I prescribed. Don't get me started about imaging...

 

We have started requiring appointments for forms but like many offices we often can't get the patient back in soon enough to get them done. I also get an inordinate number of requests to do FMLA forms for family members of the patient. Apparently there is a way to bill for those but it's complicated. And they ALWAYs call back saying that I filled the form out incorrectly. I hate FMLA forms more than anything.