Prior authorization nightmare
On July 8, 2014, I received a request for prior authorization for a patient’s prescription for Nuvigil (http://www.fda.gov/downloads/Drugs/DrugSafety/UCM231717.pdf), which is a wakefulness promoting drug used in conditions such as obstructive sleep apnea (http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/). My patient’s insurance is through Independence Blue Cross of Philadelphia (http://www.ibx.com/index.jsp). Usually, prior authorizations are processed by Future Scripts (https://www.futurescripts.com/FutureScripts/). On July 17, having not heard anything, I resubmitted, but again heard nothing from Future Scripts. During this time my patient, who was without Nuvigil, was also calling the insurance company. It was not made clear till July 21 that the company Restat (http://www.restat.com/contact/) was responsible for the prior authorizations. A representative from Restat called me to get my fax number, which I readily provided. I completed the form, faxed it, heard nothing by July 24, at which point I sent it again. I still heard nothing until 7/29, when I was contacted by Restat stating that “more information was needed” and they had not received that information from me. When I inquired what that information was and told the representative that I had twice faxed the form that his company had actually sent to me, he responded that they were trying to fax me but the fax was not going through so he was trying to clarify my fax number. Now, I had already received a fax successfully from Restat with what was presumably a request for ALL the required information. And yet, I was being told I had not provided all the required information, though the attempt to request it from me had been unsuccessful as well. Confused yet? Angry? Feel frustrated?
I explained the entire situation to the representative, expressing my concern that the patient had been without medication for the better part of the month as well as my anger and frustration that his company had now caused this patient harm. I told him that to wait 8 days for any attempt at resolution was inexcusable and unconscionable. He defended the company by telling me that they had a lot of requests to process when I asked why it had taken 5 more days after the receipt of my second fax to even respond to me. He listened till I was finished, then again politely requested my fax number, as if anything I had just said I might as well not have. There was no offer to get a supervisor for me nor any assurance that things would be corrected quickly. I hung up, as I had to begin my afternoon hours and could not wait the interminable period of time it would have taken had I requested a supervisor. I called my patient and left a message to file a grievance with the state insurance commissioner (http://www.portal.state.pa.us/portal/server.pt/community/file_a_complaint/9258). I was hoping Restat would overcome whatever internal incompetence had arisen so that they could request whatever information was possibly missing, though the form I had initially filled out contained as much data as is ever needed for prior authorizations. I had even included the sleep study report to prove the existence of sleep apnea in this patient. Though this story ends well – there never was a need for more information, and the prior authorization approval was faxed to me a short time later – it underscores again how insurance companies are playing a very active role in patient care without carrying any of the responsibility that comes along with being a doctor or other health care provider. As I asked in an earlier blog entry, who is monitoring these insurance companies? Why are they allowed to take 8 days to process a prior authorization claim (not all do, some respond to me within the day, though not always with an approval))? I urge all my readers to complain to your state insurance commissioner whenever there is a bad or even questionable outcome with your insurance company. Write to your representative and/or Congress to complain about the insurance industry and their protection under ERISA (http://www.dol.gov/dol/topic/health-plans/erisa.htm). That is the only way we can expect change for the better – get involved.