Insurance tries to make it your doctor’s fault
© 2014 Roy Benaroch, MD
Little kids don’t like to accept blame. They’ll say “someone else did it,” or “it’s not my fault”, and they’ll look at the ground and shuffle their little feet. In their hearts, maybe they really think that someone else scribbled on the wall with lipstick.
Insurance companies know better. When they’re trying to deflect blame and obfuscate, you can bet that they know exactly what they’re doing.
Just one example: prescription drug “preauthorizations”. Even the word itself, “preauthorize” – what is that, getting permission before you get permission? Did Orwell himself make that up? I have a medical license, so, in the wisdom of the legal system, I can authorize a patient to get a prescription drug from a pharmacist. The “authorization” is the prescription, the piece of paper with cryptic scribbings and abbreviations and my unreadable signature.
Trouble is, just having an “authorization” from a medical doctor sometimes isn’t good enough. Sometimes, especially if the medication is expensive, you need a “pre-authorization,” too. And the insurance company tries to make it seem like that getting a preauth is the doctor’s job, too. If you don’t get a pre-auth, that’s the doctor’s fault. Honestly, Mom, I had nothing to do with the noodles in the clothes dryer.
No, a pre-auth has nothing to do with your doctor’s decisions. My job, my “authorization,” is based on my history and physical, the decision my patient and I made in the exam room. I already did that part, and I gave you the script. Now it’s up to your insurance company to pay for it, at whatever terms are spelled out in your insurance documents. If they don’t want to pay for it, that’s their decision. It is not mine.
Insurance companies have made up a new kind of authorization, the “pre-authorization”, that somehow has also become something your doctor is supposed to do. They’ll make it sound easy—just tell your doctor he has to fill out a form, or tell her she just has to call a “prereview specialist.” Of course, it’s never that easy. I don’t have the form, and it will take days to get it. The form itself may be complicated and many-paged, and will require me to pore over your old chart to see what other medications you’ve taken and on what dates. And a phone call? Please. We wait on hold just like you do. Me and my staff are supposed to be taking care of patients, not spending 45 minutes listening to “Muskrat Love.”
Any even when we do the form, the “pre-authorization” will often be denied. We won’t know it, but there are often “secret rules” that drug X won’t be paid for until the patient has tried drug Y and drug Z for at least 60 days. Documented, in the notes that we have to send and sign. You say those medications were tried by your last doctor, and didn’t work? That’s good enough for the doctor. It’s not good enough for the pre-authorization clerk or lackey with his red rubber stamp.
After all that, the patient gets a letter, which continues to blame the doctor: “Your request has been denied, based on the information supplied by your physician.” Needless to say, your doctor can appeal this, by spending a few more hours beating his head against a tree or contacting your insurance appeals department (those are approximately the same thing.) That won’t work either, but it will further reinforce the point of this entire adventure: it’s not your insurance company’s fault. Really. We’d love to pay for your medicine. It’s just that, between you and me, your doctor just isn’t very bright. He can’t fill out a simple form. We’d do it, sure, if only that doctor would get a preauth like he’s supposed to.
No. I’m not “supposed to.” Getting pre-auths was not part of my medical education, and it’s a huge waste of time. It’s a transparent way to make it difficult for people to get medications that they need, so the insurance company can spend less on your medical care.
That letter, the one that politely refused the preauth and blamed your doctor, it’s got one other truly Orwellian component. The letter will also tell you that the insurance company isn’t dictating treatment decisions. After all, they don’t have a medical degree. They can’t decide medical things. That’s up to the doctor. Yes sir. You can have any medicine you want. We’re just not going to pay for it. And we’ll do our best to make sure you think that’s your doctor’s fault, too. And so is the lipstick on your wall.
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The Pediatric Insider 
January 6, 2014 at 11:41 am
You forgot the part where the insurance company “doesn’t receive” the document faxed back by the physician’s office. Or where they call the patient and tell them that unless the doctor calls the insurance company back in the next 72 hours (including weekends and holidays) to answer a question — but they won’t tell the patient what that question is — the authorization will be denied. Not that any of these things have happened to me…
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January 6, 2014 at 1:06 pm
OMDG is 100% right– and I am convinced that at least sometimes, inscos do these things deliberately, or at least are deliberately neglectful in the way they develop systems to handle paperwork. They seem to “lose” forms far too often to be only honest errors.
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