Don’t Get Sick Unless You Have Prior Authorization
June 4, 2017
This April, my turn to take the medical board exam rolled back around, necessary every ten years for “Maintenance of Certification.” I studied diligently for the better part of three months preceding the test (and I think I did well). It was actually pleasurable to go back over details that I had forgotten, and to catch up on newer developments in the field. I realized that I don’t do nearly as much studying, or reading the medical literature as I once did. I used to read an article or two, and browse the general medical literature for updates on a daily basis. But my priorities have changed over the last few years.
Now, instead my staff and I spend our time fighting through the incredible sea of silly red tape necessary to get paid and to get our patients even basic care. Here are the highlights from just this last week.
There was the patient with the known thoracic aortic aneurysm. The aneurysm was diagnosed about a year ago, and now requires another CT scan, as is standard protocol for the periodic monitoring necessary under such circumstances. My staff contacted the radiology practice that had performed the previous scans. They were already aware of the need for testing because they had placed the patient’s name in their recall system. However, they refused to schedule the test because there first needed to be a prior authorization completed with the patient’s insurance. The patient has a Medicare Advantage plan with Humana. Patients are being urged to go with these “advantage” plans over traditional Medicare, but these Humana plans are becoming the bane of our (and our patients’) existence. It took twenty minutes of my nurse’s valuable time to get the test authorized.
Friday night, I got a message from a type 1 diabetic patient that he was running out of his Lantus insulin. He has been on Lantus for years, and of course, needs it to survive. I spoke to my nurse, who informed me that the prescription was held up in prior authorization. The patient’s insurance recently informed him that Lantus was no longer a preferred medication on his formulary. Apparently, despite using this vital treatment successfully for many years, we now need to make the case that he has failed with Lantus to justify approval of Levemir insulin, which is now the approved insulin. We’ve learned not to obsess about things like the fact that he hasn’t failed Lantus. This is just what we have to do to keep patients like this alive in the current bizarre system.
Speaking of prior authorization, we have now been informed that we need to get prior authorization to prescribe a muscle relaxer for any patient over the age of 65. Muscle relaxers are apparently so dangerous, and my judgment as a physician so faulty, that the prior authorizers need to get involved. I guess I’ll just have to write more prescriptions for Percocet now, because I don’t have time for all these prior authorizations.
Not to beat a dead horse (prior authorizations), but now we are being encouraged to go through “Cover My Meds” to obtain medication prior authorizations. Cover My Meds “was founded in 2008 with a mission to help patients get the medication they need to be healthy…by electronically automating the medication prior authorization (PA) process, saving health care professionals valuable time and ensuring patients receive the medication they need to be well.” How wonderful! Except that my staff informs me that the process takes, on average, 7-10 days to complete! That’s about 7-10 days longer, I think, than the process ought to take.
As annoying and time-consuming as all that seems, it all takes a back seat to our recent problems trying to just get paid for patient appointments. We recently began receiving rejections for claims on Medicare patients’ secondary claims from one of our payers (I don’t use the name because, if I did, I think getting paid could get even more difficult). We have been successfully getting paid for these types of claims by this insurer for many years. All of a sudden, they are being denied.
We contacted the insurance company. They blamed our billing software. So we contacted our billing software support staff. They blamed the insurance company. Over many emails, and multiple phone calls with both the insurer and the billing software, my wife (and practice manager) was finally told that the problem was Box 11c. Previously, nothing was required in the now dreaded Box 11c. Now, we were being informed that the letters “BL” had to be typed in Box 11c. So, we tried that. The claims were again rejected. Then we were told that we need to type the name of the insurance company in Box 11c. That hasn’t worked either, though. They are working on another solution to our Box 11c dilemma.
The funny thing is that the average claim amount that is being denied is about $12. At the moment, there are twenty-five claims that we are unable to get paid. So, that’s about $300 we’re fighting for. That amount isn’t going to break us. But the amount of time that we spend trying to work around such idiotic issues may.
When I was in training, I frequently heard that doctors weren’t good at managing their practices. At that time, in the late 1990s, because of this notion, a trickle of doctors began to leave private practice to go work for larger entities, employers who would enable them to “just practice medicine,” and not have to worry about such things. Since then, the trickle has become a flood. Doctors now work for administrators who are necessary because administering health care, getting past the prior authorizations and getting paid for simple appointments, has become unbelievably and pointlessly complicated. But wouldn’t it be better, and wouldn’t we be able to “just practice medicine” without these administrators and without having to leave our practices, if instead we got rid of these idiotic prior authorizations and pointless barriers to getting paid?