Prior Authorization: Optumrx

My colleagues tell me more and more prescriptions require prior authorization (PA) from the pharmacy benefit manager (PBM). My experience obtaining authorization for buprenorphine for a patient who has been using the drug for close to ten years may help illustrate the problems and opportunities. I last addressed the subject in 2009: Prescription Preauthorization: The New Medical Emergency.

Since we expected the last PA to expire in 90 days it took neither myself nor the patient by surprise when the pharmacy faxed me indicating I would have to call the PBM, Optumrx. As usual I asked the patient to sign my agreement indicating whether I should forward a copy of the medical record at no charge or make the call for my nominal prior authorization fee of $50. The patient chose the latter, and after confirming online payment I made the call.

I navigated the usual menus until the robot told me to enter the number "we have on file." This stumped me. Not only do I not know whether Optum wants my number or the patient's, but surely Optum knows better than I what numbers they keep in their files. Time to start hitting "0" on the keypad. This roused a human, and we got started.

We quickly established the identity of myself and the patient and the details of the prescription, all of which information I had already transmitted to the pharmacy. Then the representative asked for my fax number. Having no desire to receive information from this company via fax or any other medium, I refused. After placing me on hold to confirm that Optum can continue to function without my fax number (What if I do not have a fax number?) we proceeded. Next she asked me for a diagnosis and code. I provided the diagnosis but explained that I do not know the code.

Ultimately Optum approved reimbursement for another 90 days after about ten minutes during which I provided no information that I had not already provided to the pharmacy.

The question of whether PA saves health care dollars is beyond the scope of this post. The patient's contract with the payer determines the conditions of reimbursement. Unless the physician has contracted with the payer this remains between the patient and the payer.

  • The physician has no responsibility to obtain reimbursement for drugs.
  • The physician must provide a copy of the medical record at the patient's request.
  • The pharmacy benefit manager should determine whether to authorize reimbursement based on the record without talking to the physician or requiring the physician to complete a form.
  • PAs never constitute emergencies. They are only about money.
  • PBMs do not need the physician's fax number or tax ID number.
Some physicians attempt to obtain PA during patient encounters. While this allows the patient to know what transpires, in my opinion a physician who claims such an encounter as psychotherapy or medication management risks accusation of fraud. Better that the patient pay for the service directly, regardless of whether they attend.

 

With eRx and cloud-based electronic medical records (EMR) we have an opportunity to greatly increase the efficiency of PAs. Ideally, patient and physician should grant the PBM read-only access to the record, allowing such determinations without demanding further involvement of the physician. Until EMRs implement such capabilities eRx should alert the physician to the need for PA immediately on placing the order, allowing the physician to proceed immediately to an online form requesting necessary information.

Physicians afraid to say "no" to yet another intrusion on their time by companies happy to exploit us have enabled this monster. Only when the people who purchase insurance must shoulder the cost will the payers realize they must respect physicians' time.

 

 

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