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OptumRx Sham Prior Authorization

I understand that insurance companies keep premiums affordable by limiting reimbursement, and that their contracts limit what they pay. Requiring prior authorization for drugs can encourage use of less costly alternatives. However, their contempt for physicians, as illustrated by my experience two days ago, validates the anger they engender in many of us.

After ordering a refill of Suboxone the pharmacy contacted me to pursue prior authorization at the request of the payer, OptumRx, the pharmacy benefit manager, I believe, of United Healthcare. Per my policy I asked the patient to sign an authorization indicating whether I should place a phone call for my fee of $50 or fax a copy of the medical record at no charge. The patient chose the former, so I placed the call.

After navigating the usual menus I spoke with an OptumRx representative who interrogated me to confirm my identity. She demanded to know my first name, even though I use my first initial. I provided my office address and NPI number but refused to provide a fax number. (I do not want anything faxed to me from these people.) She told me she found no record of need for a prior authorization, but offered to fax a document or form of some kind as an alternative to a “considerable wait” for another representative.

After only a few minutes Charlotte took over. She asked the patient’s diagnosis and even helped me with the ICD-9 code. She asked whether I have a special DEA number for prescribing buprenorphine for treatment of addiction. She asked whether the patient needed the authorization urgently. I suggested she might want to ask the patient, and that any further delay might provoke a very angry response from the subscriber.

Charlotte approved reimbursement for one year.

Charlotte never asked for any further information about the patient. The entire 15 minute process provided OptumRx with no clinical or other information that was not already included in my prescription order (since use of my special DEA number implies the diagnosis). The entire exercise did no more than establish my identity, falling short only of obtaining my photo ID, fingerprints or Social Security number, while wasting costly resources and achieving no saving of health care dollars.

Well, maybe OptumRx saved a little money. By springing the need for prior authorization with no advance warning they forced their subscriber to pay for part of the prescription out-of-pocket.

In a competitive market the subscriber could switch to a company that behaves better, but we do not have that here in America, even after implementation of Obamacare.

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