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Prescription Preauthorization: The New Medical Emergency

It’s 5 PM Friday, and you’re closing the office for the weekend when you receive a fax from a local pharmacy informing you that you must call an 800 number or complete a form for your patient’s health insurance company or there will be no reimbursement for the drug you prescribed earlier in the day. The patient, who may still be waiting in the pharmacy, needs a 3 month supply to take on a trip to England leaving early Saturday morning. Emergency!

The insurer is placing you in the awkward position of choosing between compliance with the demands of an entity with which you may have no direct relationship, possibly compromising your relationship with your patient, or leaving your patient with no access to needed medication for three months unless the patient elects to pay cash for what insurance might – or might not – pay for if you jump through enough hoops. Your patient will also likely expect you to say whatever it takes to get reimbursement.

When the pharmacist provides you with an 800 number you must call for preauthorization she probably thinks she is helping you. I think it’s rude and presumptuous, and a waste of time for the pharmacist. The pharmacist should ask the patient or the insurer to contact the physician. Most insurers seem to offer a choice of telephone contact or completion of a form to be returned to the insurer.

Let’s do some reality testing. As physician your duty is to the patient, to diagnose and treat, not to obtain reimbursement or to help an insurance company make a decision about reimbursement. You do have a duty to provide a copy of the medical record to whomever your patient wishes. The high cost of prescription drugs is a product of our free market economy. Don’t accept responsibility for that. Neither should you feel responsible for knowing the prices of every drug available. (I admit, though, that I do tell my patients they can get fluoxetine, paroxetine and citalopram for only $4 a month at some pharmacies!) You as physician have no duty to expend your time in order to help the payer complete a process that will enable them to deny reimbursement and improve their bottom line. You certainly should not distort the facts (lie) to get the insurer to pay for the medication. A written contract governs the patient’s relationship with the payer. The patient has agreed to the terms of that contract, and the patient, not the physician, is responsible for knowing whether the payer can demand preauthorization.

Potential for negative health consequences, not financial consequences, makes for medical emergency. Request for preauthorization does not qualify. Preauthorization, like other reimbursement related matters, should assume low priority in your practice compared to clinical matters. Accomplishing it during the next business week should suffice. If we refuse to treat these requests as emergencies, payers can develop more reasonable approaches, for example by paying for the first prescription without preauthorization but notifying the patient that future orders will require review. Furthermore, regardless of how pharmacist, physician and patient respond, the preauthorization process may lead to costly delays, even threat to the health of the patient, and may lead to necessity of another contact between physician and patient to discuss an alternative, affordable, treatment.

Before you engage in providing preauthorization information to a payer your patient should understand that, assuming you provide correct information, reimbursement may still be denied, and that this is not the physician’s responsibility. The patient should pay the physician for this service. You should offer to simply provide a copy of your record to the payer in lieu of answering questions on a form or by telephone. Let the payer decide whether to reimburse based on the entire record instead of your answers to a few questions. Since this involves providing more – or at least different – information, with different implications, than what you routinely provide with a claim form, you should obtain from the patient separate informed consent for release.

In my practice I contract with no payers. My initial application and policy statement informs patients that I charge a $50 fee for preauthorization, payable in advance, and that the patient must first agree to the terms outlined in my preauthorization form, which states that I will provide a copy of the record at no charge instead and that the payer may still deny reimbursement. I also tell my patients to call the pharmacy to make sure the prescription is ready before going to pick it up.

Third party payers will respond to complaints from subscribers, not from physicians or pharmacists. By caving in to escalating demands from payers providers validate and enable policies that only transfer costs from insurers to patient, pharmacist and physician. The role of a physician is to diagnose and treat illness, not to obtain reimbursement. Don’t enable insurers to manipulate you or to redefine medical emergency. We must also honor patient requests to provide records to insurance companies, but by engaging in the preauthorization process without being paid by the patient we may transgress ethical boundaries. Patients should pay a nominal fee for physician participation in any review process with full understanding that the physician accepts no responsibility for the outcome. Only when physicians take control of this process will our patients demand reasonable behavior from insurance companies. And this is another good reason to avoid contracting with them.

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