How many of you have been to your pharmacy to pick up a prescription, only to be told, “We cannot fill that because your insurance company requires prior authorization.”? You went to your doctor, you got your prescription, you go to the pharmacy, and it should be a simple matter of paying your copay and that’s it, right? Unfortunately, insurance companies have become increasingly intrusive in this particular practice of denial of care. And why? If you ask the insurance company, you’ll get canned answers, such as “that is what your plan allows,” or “you should talk to your employer about a change in your benefits.” They’ll never admit the real reason is cost containment, so even though they are involved in the clinical decision making process, they hide behind administrative double talk and escape culpability. While it is true that medications are costly and drug companies spend a huge portion of their budget for any given drug on marketing and sales, it is still unconscionable that an insurance company can deny your care because they need to produce a positive result for their stockholders. Take a look at what their upper level administrators and executives earn. Often, they earn as much or in some cases more than some of the highest paid athletes. It’s hard to believe with that kind of astronomical revenue there cannot be some sort of trickle down effect to make care more affordable. And before you think that the court of law may be a place to air these grievances, consider this:
ERISA, the Employee Retirement Income Security Act of 1974, is a federal law that establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans. ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries. Unfortunately, insurance companies saw an excellent opportunity to use loopholes present in the act to immunize themselves from legal liability in medical malpractice. Deny an admission for a suicidal patient and that patient is discharged and commits suicide? The doctor and the hospital have all the liability. Determine a treatment to be “experimental” and the patient dies or significantly worsens? Too bad, it’s on the doctor and/or hospital to come up with a better solution. Every day doctors have had to wrestle with their own set of medical and personal ethics each time a potentially expensive decision had to be made. And I would like to believe, and indeed I think statistics would back me up, that most doctors would ‘err’ on the side of patient safety and health no matter what the cost. So who pays for all of that? Not the insurance companies. We do.
There exists a whole cottage industry of prescription benefit management companies that may be independent from or subsidiaries of insurance companies. These entities are truly an industry that, while certainly providing jobs for many, offer no actual service or product to the country. Their sole existence is focused on saving money for insurance companies. Doctors have often gone to work for these companies with the hope they might be able to promote positive change from within, but in most cases they end up as gatekeepers too and if they allow too many non-formulary agents, they might see themselves out of a job. Doctors and their staff spend hours of unreimbursed time fighting to get medications approved and they have to justify almost every decision to someone who, in all likelihood, has far less training and may very well be reading from some closely guarded algorithm sheet when determining whether or not a medication can then be approved. Often, even after successful completion of the forms, the company will then place a follow up call for “clarification,” which is a relatively newer phenomenon. And this call, if unanswered or not responded to in some timely fashion, may hold up the prescription further and is typically made seeking to verify what’s already been stated. It took me 8 weeks and a whole lot of digging around online to find people in authority who I then called before I got a disabled patient’s medication for restless legs approved. Eight weeks! Eight weeks! In the past I worked as the medical director of an outpatient day program and had to do what is called a “doctor-to-doctor” review because apparently there were questions about why the patient still needed treatment. The doctor doing the review with me made a suggestion to add some other medication that the I felt was not appropriate. After I thanked the reviewer but said I was not implementing the suggestion, the other doctor subtracted one of the newly re-authorized days. When I asked why, and I quote verbatim here, he answered “because I felt like it.” Because he felt like it.
In my practice, I maintain a well organized database of prior authorization forms for all of the insurance companies I encounter. In many cases, the insurers will not make these forms readily available, as it seems that they want to send me their form at the time of the request for prior authorization. Searching their websites is often an adventure I’d rather not have, as the forms are often either unavailable or difficult to find. If I know a medication is going to be a problem, I will fax the requisite form in before my patient even gets to the pharmacy and I always warn patients when I think there is going to be an issue. I often suggest that if my patients are unhappy with an insurer’s decision they submit a grievance to their state’s insurance commission. Here are the links for patients who may be under my care or live in the general vicinity:
Pennsylvania: http://www.portal.state.pa.us/portal/server.pt/community/file_a_complaint/9258
Delaware: http://www.delawareinsurance.gov/services/filecomplaint.shtml
Maryland: http://www.mdinsurance.state.md.us/sa/consumer/file-a-complaint.html
New Jersey: http://www.state.nj.us/dobi/consumer.htm
Many times, with the proper form, the process, while an unwanted addition to patient care, is seamless. In about 25-30% of the cases, though, there is a glitch of some sort. There is always an appeal process, but what I have been doing and have found more effective is traveling the e-mail and phone chain till I get a hold of a medical director. It never pays to engage in a hostile fashion, so usually I approach this on a friendly basis and have been pleasantly surprised at times that the person on the other end of the call is willing to help. In one recent case he admitted that his company’s process was flawed (the process of getting this one person’s medication approved was monumentally tedious and frustrating but it got done). He agreed to set in motion changes to streamline their process as a result of this call. I feel it is important for people to be educated about this part of health care so as to be able to engage doctors in meaningful dialogue about it and be able to participate in the process when and where it is possible.
Thanks for your time.. That was very informative.