Wednesday, October 14, 2015

Preauthorization Frustration

In a note sent to my congressional senator:

I am a psychiatrist in Maryland  and I have become interested in the issue of the hoops that insurers require physicians to jump through to get preauthorization for medications.  Given that medicine, and psychiatry in particular, is a shortage field, it seems criminal that insurers can require physicians to spend hours requesting preauthorization for medications.  If the process were simple, this would not be so bad, and certainly some medications are quite expensive with cheaper available alternatives, but the process can go for weeks, during which time a patient can't get medications.
There are also many times when physicians are required to make these calls -- often taking 20-30 minutes-- for medications that cost only a few dollars a month -- the obstacles are mindless and they are hurting the delivery of medical care.  
Each state regulates this, but the issue often crosses state lines.  I have been trying to get a medication approved for a patient for weeks now -- I practice in Maryland, the patient lives in an adjacent state, her insurer  is in Iowa, and the pharmacy oversight agency is in Nevada.  I've been required to make multiple calls, all with hold times, where I am asked the same questions and told that the patient does not have medical necessity for the medication.  They ask the same questions at each step and tell me that while the case for the medication is good, they have no leeway to authorize it.  I have communicated with the CMO of the insurance agency who simply confirms that this is the process.

The process is well-illustrated by Danielle Ofri in a New York Times article last year:Adventures in Prior Authorization.  What she doesn't say is that there are no limits or regulation on how long an insurance company can delay or how many hoops can be set up.

I know Senator Cardin is sensitive to mental health issues.  Rep Murphy of PA has a bill in congress -- the Helping Families in Mental Health Crisis Act -- where he discusses the shortage of psychiatrists, but I don't believe it addresses this issue.


And in one of several emails to the health insurer's chief medical officer:

Yes it would be good if this process could be expedited.  I have been trying for weeks to get this medication for this patient.  I spoken to several people at both Catamaran (the pharmacy benefit agency) and Wellmark.  None would give their full names, and none had the authority to approve the medication if certain questions were not answered 'yes' and there was no room for individual consideration.  Yesterday, I saw the patient to get the release sign, and I noticed that the appeal and release are to be mailed (postal mailed that is) to different addresses, and only the release can be faxed.  I am going to assume that there might be some difficulty in getting these to the same place in a timely manner for review, and during this time the patient continues to suffer.  There seems to be no mechanism for electronic submission.  This process has taken now hours of my time, and it has been weeks.  I am going to attach the appeal letter in the hopes that perhaps as medical director you can get it to the correct place.  I will also mail it, and fax the release.  
Apparently I'm not the only frustrated psychiatrist, Dr. George Dawson at Real Psychiatry has plenty to say on the topic here:


George Dawson, MD, DFAPA said...

There is really no reason for prior authorization and it should be banned:

George Dawson, MD, DFAPA

Dinah said...

Thanks, George -- I added your link to the text of my post.

clairesmum said...

hoping this makes a little dent in the armor that protects this gigantic tangle of mangled care that serves only the investors in the business of health insurance.

Anonymous said...

About five years ago, I was going off an edge emotionally, and my therapist jumped through a lot of hoops (probably many more than I am aware) to get me the care I needed. I am in a much better place, and I am grateful.

Thank you for fighting for your patient. It matters.

moviedoc said...

It's not a physician's role to get money for the patient. The insurance contract governs what the insco will reimburse. Charge the patient a fee for performing a prior auth that involves talking to the insco, and let the patient know if they representative just wants info the patient could have provided. provides a very easy way to do this. Almost every pharmacy I have asked has agreed to use them. EMR Practice Fusion supposedly incorporates PA now. I disagree with George. If payers don't control costs, premiums will continue to rise, and predictably, drug costs are rising related to increased demand secondary to Obamacare covering more patients. Let the patients fight for reimbursement. The LAST thing we need is more regulations. Get the government OUT of medical care.

Anonymous said...

Do you have to get preauthorizations for every medication prescribed? Or is it just certain drugs and certain insurance companies that require this?

Dinah said...

Moviedoc-- The pharmacy company in this case --Catamaran-- does not use covermymeds >I asked. The patient is too ill/compromised to negotiate this, it simply wouldn't happen, and as is, we are waiting for a hospital bed.

Anon-- If this level of preauthorization were required for every medication, medicine would collapse. It seems to be required for certain expensive medications (provigil, Abilify), for unusual dosing, and randomly for cheap medications. I think the figure is roughly 30-60 minutes a week of doc time. Read the article by Danielle Ofri.

George Dawson, MD, DFAPA said...

On the issue of "payers controlling costs" it is very clear that is not happening.

The payers in fact are directly subsidized by the federal and state government for their role as middlemen and the failed political theory that they control costs. They are no costs savings to the patient or the taxpayer who is really footing the bill.

Any savings is profit for the company or PBM.

What has happened to the mental health infrastructure in this country in the past 30 years is the best example. Inpatient care has been nearly destroyed and currently occurs in jails where it is cost shifted to the taxpayer. Managed care companies shifted the care of the severely mentally ill to the states and the states gradually used managed care techniques to shift the cost of care to law enforcement.

All that time they were not having to pay for treating addiction or mental illness - premiums were increasing and now we have almost universal high deductible plans. We also know that the average out of pocket costs for a retired couple on Medicare is about $250,000 over the remaining course of their lifetimes.

Managed care does not save anybody any money or control costs.

Joel Hassman,MD said...

I just can't fathom how people continue to try to rationalize and be respectful to a disgusting intrusion into care that is flagrantly irrational and profoundly disrespectful to both patient and provider.

Preauthorization is a frank disruption of clinical care, it can't be shielded anymore by this false claim it is simply about cost, and when some honest and concerned lawyer can take on a case that has lead to profound morbidity and mortality to then draw in the insurance industry for the consequences of poor clinical care decisions, only then will insurers shut up and stop this hideous practice.

Or, I guess we'll have to have a real life "John Q" moment that impacts on the American psyche per some horrendous incident to make the general public finally wake up and say "oh, I didn't know that!"

No pain, no gain, how ironic that catch phrase will come to define America in future history assessments, eh?!

By the way, my take with authorizations is simply this: I don't have the time nor patience to legitimize my prescribing habits to a non clinician, or at least not a peer equivalent one, and so if patients want my expertise and recommendations for clinical care, they need to do much of the work to track down these forms and have them sent to me. Because lawyers in Malpractice Insurance tell us simply this: no paper trail, little defense of your outcomes. Don't do this over the phone, it has no substance to defend you as a provider should the patient crash and burn.

Plus, I hope to use the documentation as a noose, hopefully when lawyers come calling on me to be a possible witness against an insurer in future times documenting how these authorizations are in fact clinical care intrusions, asking for clinical information and claiming they can direct care decisions.

Hey folks, what else do you need to finally realize insurers have no interest in caring about their customers, and that is the key word here, "customers", which I have to accuse almost all of you being complicit in letting health care become a business and be run by business principles.

Profit and providing care are incongruent concepts to be lumped together. But, for those who argue otherwise, what is the color of the sky in your world???

And I end with this image for readers to amuse themselves per the sign off request by this blog site...

Anonymous said...

I think rather than nickel and diming the patient for things like preauthorizations like moviedoc suggests you could do what my psychiatrist does and not use the full time the patients are paying for so you have a little cushion of time to take care of things like preauthorizations, phone calls, etc. I see my doc for medication management and when I am stable I don't use the full time I am paying for. I think I'm paying for 20 minutes for medication management, and I have used the full amount of time maybe twice. A couple of times I've gone over the 20 minutes. When I'm doing well there's no need to talk about how well I'm doing for 20 minutes. So, if my doc has multiple stable patients who are not using the full time they are paying for that adds up to a considerable amount of compensated time to take care of things like phone calls, preauthorizations, etc. My doc is being compensated for his time.


Dinah said...

P-K : I see patients for psychotherapy. The CPT billing codes determine that a certain number of minutes be spent on psychotherapy and be differentiated from the amount of time spent on evaluation and management (the part of the session that is about medications, symptoms, and side effects). The time must be face to face, so if I cut people's session short, they are getting less therapy and they will get less reimbursement. My sessions run for 60 minutes -- 53 minutes of therapy and 7 of evaluation/management. The patient would get reimbursed much less if there 52 minutes of therapy (see my old posts). A five minute session, even without psychotherapy, should be coded differently than a 25 minutes session for evaluation and management. Since I don't participate with insurance companies, I should care what my patients get reimbursed, but I like to think that I'm trying to help them be able to afford therapy. I may just be nuts, because I never know what becomes of the claim sheets I hand them.

Moviedoc is right that it's not a doctor's job to get reimbursement for the patient. Maybe I should invest in a few sessions with him.

Anonymous said...

I didn't realize 52 minutes versus 60 minutes would make that much difference in reimbursement. I guess it's more difficult with psychotherapy to carve out extra time. Also, I want to be clear that my psychiatrist is not pushing me out of the door after 5 minutes, it's just that when I'm doing well I don't feel the need to hang around chit chatting. I'm always ready to go do something else.


Dinah said...

Case in point:

R said...

(Former insurance regulator)
I would suggest filing a complaint and appealing to the patient's state insurance regulator.

My jurisdiction has a binding independent medical review with a 2-10 day response time depending on urgency. In practice, emergency review was often completed in less than 2 business days.

The only catch is that the insurer has to fall under jurisdiction - so if it's a business' self-funded plan you're out of luck.

Dinah said...

Unknown: I did complain the patient's state insurance regulator and they did get back to me promptly and it was a self-funded plan and I was out of luck.
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