Tuesday, April 29, 2008

Can I Get Prior-Authorization To Kick Your Ass?

Whoever decided to put high-school dropouts in front of a computer with headsets on to speak with physicians or medical providers to discuss and approve or deny drugs or other therapies for patients was a real fucking genius.

Let me tell you how it usually goes when I try to get a wonderful, newer drug approved for my patients. I love Byetta and prescribe a ton of it. It is the only commonly-used drug for type 2 diabetes that lowers glucose AND helps patients lose weight. Unfortunately, since Byetta is newer and more expensive than your typical, cheaper generic diabetes drugs that cause FURTHER weight gain in these already-obese patients, it often required pre-approval from insurance carriers. We'll start with how the prior-authorization call usually goes (in reality), then we'll slide into the 'Twilight Zone' where both me and the insurance company customer service rep say what we actually WANT to say to one another.

Dr. Lofty: Hi, I was asked to call to get prior approval for Byetta for my patient.

CSR: Yes?

Dr. Lofty: Yes?

CSR: And your question is?

Dr. Lofty: My question is, what information do you need to get this drug that I believe my patient should be on approved?

CSR: Yes (pause, looking up algorithm for questions to ask caller under 'Byetta protocol'), so why does this patient need Byetta?

Dr. Lofty: Because they have gained 20 pounds over the past year on Actos and glyburide and in my experience I can get this patient's hemoglobin A1c down about 1% with about 20 pounds of weight loss using Byetta and getting them off of these other drugs.

CSR: I see. And what is the medical justification?

Dr. Lofty: I just told you the medical justification.

CSR: Yes, well, I'll need to fax over a two-page prior authorization form that will need to be filled out completely along with the last three chart notes documenting failure to achieve control with....


Dr. Lofty: Hey fuckhead with your G.E.D. diploma hanging on your cubicle wall, I went to fucking medical school for four years, did three years of residency training plus a chief resident year, and have been practicing diabetes almost exclusively for ten years. My experience tells me this patient needs Byetta and I want him to have it NOW! Losing weight and shrinking the waist probably reduces cardiovascular risk in patients with type 2 diabetes.

CSR: Sir, we really don't give a flying fuck if your patient loses weight. We would prefer he or she remain on the cheaper, generic drugs that they are currently taking.

Dr. Lofty: Well, the patient sure would feel better in the long run losing twenty pounds and losing about 2 gallons of fluid from their legs.

CSR: Again, don't give a shit about this patient's quality of life. Too expensive to use this drug. This person won't be on our plan in two years, so we could give a rat's ass whether or not they lose weight or feel better. They'll be someone else's problem in two years.

Dr. Lofty: You're a dirty fuck stick...I hope you gain 200 pounds today and develop type 2 diabetes. You'd be begging me to put you on Byetta and I would give you shitty drugs like glyburide and Avandia to make your fat ass fatter!

CSR: Whatever. You doctors are so arrogant.

Dr. Lofty: Hey, Einstein. Can I talk to your supervisor? I want to get the ball rolling on a prior authorization to come down there and kick your sorry little ass!


  1. Would you please call my insurance company? Please?

    My insurance will pay "up to $25" for a psychiatrist per visit. As I have discovered, Psychiatrists do not do counseling, they only write prescriptions. At least here in the sweaty Southeast that is how it goes.

    They won't touch a counselor regardless of how many letters they have after their name.

  2. s in my d,
    go see a doctor of psychology. they will sit and talk with you and your insurance should pay. they are doctor and if they think you need meds a psychiatrist will then prescribe but they prefer the couch route.

  3. Out here in California psychiatrists definitely do counseling, but only for those patients who can pay for it themselves. They actually would love to do more therapy, they just don't have patients that can afford to pay for an hour of their time, and insurance won't cover it. The one time I needed therapy a psychiatrist helped me enormously (I was also taking antidepressants), but it was expensive. He missed therapy so much he gave me a teacher's discount.

  4. The title of this post is cracking me up!

    I hate when the insurance company thinks they can decide which drug the doctor should give. There is a reason the doctor is the doctor and the insurance representative isn't! When my son was having his stomach problems, his doctor and I spent hours convincing the insurance company that whatever drugs she prescribed each time were the drugs she actually wanted him to have. I feel for you having to deal with this!

  5. Thanks, Rad Girl. I aim to please. Funny, I pretty much actually had this conversation with an insurance company today! Same drug, same discussion, same outcome. If I actually get on the phone and waste 10 minutes of my time, I actually get the drug approved quite easily. But, why can't my medical assistant accomplish the same thing while I am in SEEING PATIENTS????

  6. The red tape and beauracracy really bother me. Why can't anything be easy. Has anyone heard how John McCain is trying to bring free market back to medicine. That's the blurb I herd on Fox news. Rudy G. thinks that people should just buy their own insurance and shop around without going through employers.

  7. great post lofty. imagine getting these preaproval forms in the ED 2 weeks after you have seen the patient you don't remember in the first place.

  8. I am with you, S-cat. What a nightmare. How's the 'exit plan' going by the way???

  9. "I hate when the insurance company thinks they can decide which drug the doctor should give."

    I ain't picking on you, but many think of this process within the wrong paradigm. It is you, and you alone, that decides what drug to prescribe. Patients have an independent agreement with insurance companies such that the company will assist in reimbursement of drugs, with stipulations.

    The patient is always free to go outside and purchase the drug. Furthermore, docs are often fooled into performing preauths when the financial benefit to the patient may be marginal - $10 - $50. Yet patients inappropriately expect this unreimbursed service to be provided by your office. There is no contract that stipulates you as the patient's envoy for partial drug reimbursement.

    There are several solutions and I take issue now because it has been sop. It is approaching the point that whining about it looks trite. You should have a policy in place for the office -- charging, denying, time frames, whatever, that is followed by default, with the physician making exceptions for those certain patients that are "labors of love."

    JMO. Mike

  10. Oh... this post sounds so familiar. I hear co-workers (and their doctors)having to argue for weeks before the insurance will sell them "what the doctor ordered." I think the reason it takes so much arguing, is that in the meantime, the insurance hopes the patient will run out of meds and die. Then, problem solved. Next!
    It is just an evil ploy. :-)

  11. mike,
    are you high? i have patients demand prescriptions for tylenol and motrin because 'i can't afford it and my insurance will pay if i get a scrip'. so the insurance co's have responded with the above ridiculousness. lofty is not exagerrating. i don't care what you see written on paper, he deals with it, and i do too, every day. all of this because of the federal govt. sticking it's nose in in the first place. the market is not dumb and people are not either. if some get our services for 'free' then others will pay and payors, ins. co's for instance, will impede costly drugs and procedures with idiots on the phone.
    ps you chose your screenname. do you wear it as a badge of honor or as a joke?

  12. My endocrinologist is pretty cool, but, now that I think about it, I guess I'd prefer one that used the word "Fuckstick" more.

  13. My endo DOES use the word fuckstick. I love him so very much because he makes me laugh like crazy every time I see him. He reminds me of Joe Pesci but older.

  14. This comment has been removed by the author.

  15. 911

    I have to believe the name is a joke. The subject was covered well by lofty, and needs no further comment.


    The exit is going ok. Still in the initial stages, but I'm excited about the possiblity of leaving the ED. Will make less, but I don't care because less will go to the gov-ment to pay for shit for people that don't pay into the system in the first place. (2007-6.5 million taxpayers (5% of the total 130,000,000 returns) paid 57%of the total personal income tax in the U.S., yet are still viewed as under taxed) I am trying to be downwardly mobile in what is gradually becoming a more socialist nation so it won't be such a shock to the system when it all is taken away.

  16. Richter:

    My co-workers have to order their meds from a mail order pharmacy that sells and decides what people should or should not take. If they have the power to decide and argue with doctors, they obviously belong to the insurance industry.

    And please, go away. You annoy me in a tiresome way. Yawn.

  17. Ah well, a little baby-sittin' will keep our blood pressure low. Way to go with the CAM 911!

  18. Clozaril... the psychiatrist's nightmare.... oooohhh the paperwork hurts! Every two weeks!!! "You want us to send you WHAT?" (A previous job... in a previous lifetime)

    You have my sympathies....


  19. Can't you just delete Richter's comments rather than moderating EVERYONE'S comments?

  20. Lofty:
    Great post. This is the shit that drives docs out of medicine...

    I think 'Mike' is being sarcastic... I REALLY hope so. If not, he may be just dumb enough to get a job with an insurance company.

  21. I have to agree with Mike's analysis. It's not that the patients can't get the medication it's just that they have to pay for it. It usually turns into something like "The pharmacy refused to give it to me or "My insurance said that I couldn't have it". It's not that at all. It is just that it will cost them more.

    It's kind of like when Medicaid patients come into the office without their card. We tell them up front they have to pay full price for their visit. This turns into "The doctor refused to see me". And again, it's not that we refuse to see them it's merely the fact that we told them they had to pay full price for their visit. Which they refused to do.

  22. nurse k,
    no, i got twenty comments from her around midnight last night and couldn't delete them fast enough. she just kept sending them in on many different posts. richter wins the battle, we will win the war. turns out she has a crayzee blog. kinda neat if folks were to give her a taste of her own medicine don't you think?

  23. And here I thought you were finally gonna moderate that pathologist and his 4-letter C-word.

  24. Gosh, wouldn't it be a hoot if docs could act like, yanno, docs and not have to constantly look over their shoulders to see what some zit-faced insurance weenie is going to say? I weep for the future of American medicine.

  25. What's really fun is calling and explaining to the insurance company that they've calculated the miles to a Doctor using air miles and I'm not willing to drive three hours to take my kids to the Pediatrician. We drive around an ocean inlet and through the mountains - I explain over and over. They just slap a ruler on the map (over the Alaska range) and call it 50 miles. rrrgh.

  26. How about...five faxes (the first three dumped in the wastebasket by the insurance co. without bothering to reply that the form on their website was the wrong one, the fourth lost by the insurance co. despite a phone call right after the fax to make sure they got it, and the fifth finally going through) plus three long phone calls to finally get a pre-authorization?

  27. Sadly, this is all because a couple of decades ago they tried to 'fix health care' by tinkering and making a thousand little patches, and thus creating a huge bureaucracy that just makes everyone miserable except those still making money from it, of course. This is why you have to overhaul the system itself.

    Oh and getting mad at these intermediates who talk to you the phone is fruitless because they, like good soldiers, are just 'in the trenches' doing what they are told and are only the messengers for the evil and corrupt decision makers who are comfortably and conveniently not available to deal with the problems they created. That is why we as docs should not get upset either. It is not worth sacrificing our own health to a morally bankrupt system that sees patients and Docs/providers as mere commodities.

  28. agree almost completely. only take issue with the statement that the flunkies on the phone are 'good soldiers'. they may or may not be. if they understand what they are involved with then they would, as good soldiers, quit.

    i agree that we as doctors should not get upset, especially at each other... many docs don't understand that with some exception we aren't really mad at each other... we are put in positions by the bureaucracy that get us mad, then we take it out on each other.

  29. All hail the awesome doc who calls it like it is. I'm dealing with my own Rx insurance nightmare (& yay! I'm 1 of the sick farks who has to leech onto the "gubmint teat" for this option because I am a medical train wreck) & after being assured & outright lied to after wanting to choke the living crap out of my former insurer for constantly insisting that just about every 1 of my meds needs a prior authorization, which I feel is abusive to physicians, as your time is already overburdened with shit loads of paperwork to be done thatnks to sue happy assholes, so my new insurance company, Fox Insurance Co. has it's call center in India, where the help is paid fuck all & due to cultural differences, really couldn't give a hoot if you get your Rx's approved or not, especially when a few of them cost more than they make in a year. I suspect that you'll be getting more traffic here, thanks to the fact that the braindead fuckos in Washington DC finally caught wind that Fox Ins. Co. is trying all they can to deny patients their medications. This is a fucking nightmare which is only worsening & until the Rx insurers start hiring people with an understanding of health care aspects, I suspect things will get much more insane. I'm curious to know how long it takes you fine physicians to fill out these forms & at what rate are they approved/denied?
    I see that I'm a little late in this quest, as you posted this almost 2 years ago, but perhaps if you or another doc sees this, you can answer me. Again, with this Fox Ins. Co fiasco, expect more visits to this page...

  30. I would like to say that, I pay for health insurance, so I expect something in return. I can afford to pay a doc. visit and am a professional in the engineering business. I can pay 30$ with the insurance because I PAY a monthly premium. If I choose to just pay the full price (read sarcastic as you wrote it) I would pay 200$, so why am I paying my insurance premium again? Is it impossible to have a person answer the phone in your office perhaps?