Posted tagged ‘healthcare costs’

Navigating the pre-authorization nightmare

February 17, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

If the size of my stack of paperwork is any indication, 2014 will be the year of the pre-authorization. If you want coverage for a medication more expensive than aspirin, there’s a good chance it’s going to cost your doctors and their staff a mess of time and headache as they fight their way through flaming hoops of paperwork and phone trees.

Press 1 if you are a provider, press 2 if you elect to have red hot pokers jabbed into your eyeballs.

After a while, option 2 sounds better.

In a normal world, obtaining a prescription would work like this: you see your doctor, you share your concerns; a diagnosis is reached, and if a prescription is appropriate you discuss the pros/cons, the side effects, and anything else you need to know. Then you take your little piece of paper to the pharmacist, who gives you the pills. You pay your copay or whatever, and then continue with your life.

In 2014, there’s often an extra step. The pharmacist on her computer is told that a pre-auth is needed. Faxes fly between the pharmacist and doc, and we end up with multiple copies of a different form for every medication on earth, with all sorts of questions and little boxes to check off. Every drug has a different set of boxes, and — fun!! — we don’t know which boxes will get the drug covered. Even if we correctly get the boxes right, we’ll find out later that the medicine won’t be covered unless, say, the patient has already tried 2 drugs from group A and 1 drug from group Z (those come with an egg roll) for a minimum of 6 weeks, or 4 weeks in a leap year. And we have to send those records, and the egg roll, and a copy of the doctor’s organ donor card to the Lieutenant Governor (this is required to be sent by burro.) If the burro is late, we have to start over.

And, needless to say, half the time the insurance company will claim they didn’t get the fax. Or that the burro got lost. So we have to start over again. It’s like running a maze—except we’re blindfolded and don’t know where the walls are. And anytime the insurance company wants, they can send us back to the beginning at the crack of a whip.

Meanwhile: the patient waits. And fumes. And maybe says, “Forget it! I’ll just pay for the stupid medicine!”

Which means the insurance company wins.

Bonus for the insurance company: all of this makes the patient angry at the pharmacist and doctor, deflecting blame from their own oily “customer service” hides.

There are ways you can work together with your doctor and pharmacist to help fight this pre-auth nightmare: