Uf And All The Das...

 Yeah, probably a Minnesota joke most folks won't get.  But that's how today's "Monday" went.

Without violating the various health care privacy laws, I'll pull a little curtain aside for my Day Job.  As an Authorization Specialist, I'm the guy who talks to insurance companies and other folks who pay for medical services, on your behalf.  That means I have access to an awful lot of information that the insurance company is going to want to see to justify the expensive (in their terms, anything more than $0.02 can be that, depending on the organization and direction of the current breeze).

So in basic terms, I'm asked to look at the prescription your doctor wrote.  Thank all that is Holy that most doctors these days use computers to generate those things, so I'm not often left looking at some twisted art project trying to turn it into a twelve-letter name for a medication.  Or something along those lines.

Anyway, as my employer pretty much focuses on one part of the overall therapeutic service environment, it keeps things easier for me.  I look at these orders, figure out what the medication is, how much each dose is, how many times a day you're supposed to be getting it, and for how many days.  This drives the bus in terms of telling me what I need to ask your insurance to approve, how much, and for how long.  I don't know pricing, all I know is that we have a contract, there are some things that are specified in dollars, but those numbers could have changed.  So no, I don't know down to the penny what I'm asking for.

What I am doing, however, is looking through the medical records trying to find the part where the doctor explains to you and to his coworkers this is the thing they found that's wrong, this is the medication that is best-suited to treating it, and this is how long it should take.  I take that document, add it to the orders, and then the fun starts.  

Some organizations have tools I can use.  I go to the tool, put in the code that represents the medication, another code that represents the "DME" - Durable Medical Equipment - that pretty much gets the medicine from the container the pharmacist puts it in and into you.  And sometimes the service is far more complex and requires several medications.  And several pieces of equipment.  And sometimes the organization doesn't have a tool, they have a web site, and I have to jump through a bunch of forms and supply all of the information I've collected, then send them the documents.  They'll review my information AND their own internal requirements, see if the medication does fulfill the needs the doctor has identified, and the people who haven't seen the patient then make a decision whether the medication is, or isn't, appropriate.

And then there are those organizations who really want to go back a few decades or so, so I end up filling out a form and faxing it, and the documentation, to them.  Then I have to call and make sure they not only got but could read my fax, and then I wait for them to review and return it.  And most of these folks will tell me yep, we got it, it's going to be 15 calendar days for us to decide.  Sometimes this actually does take 15 days - as in I do believe they sit on these requests for 9-12 days, then pass them out and ask people to make a quick decision.  It often seems that way, based on the quality of the questions and or reasons I get when they tell me no, they aren't going to approve it.

But there are some organizations and tools that will give us the "No Auth Required" response.  Or the NAR.  Which is, and isn't, a good thing.  The way our systems work, we need to review those things annually.  Which means we had to pick a date when everything changes over and we start over.  And since most folks who are going to change insurance do so at the end of the calendar year, all of our "No Auth Required" approvals have to be re-evaluated around the first of the year.

Or to put it another way, when I punched out Friday night, we had a little over 200 tasks that were headed towards, or had already, expired - which means the dates for their approval had ended or were within two weeks of ending so we had to check - and make sure the patient was not going to be getting the medication any more, or if they were, we needed to make sure we had new orders, new clinical documentation showing that yes, the therapy is effective, the patient is improving, but if we end the therapy, they're not going to continue to do well.

That's not a call I make.  That's up to your doctor.  I'm just the conduit that connects your insurance company to the documentation your doctor gave us, telling us yes, the service is beneficial, appropriate, and necessary - and has to continue.  Then we make the case to the organization that's going to pay for it. 

This morning, when I logged in, that same task list that had a little over 200 tasks Friday was a bit over fifteen times that.  Yeah.  So when I stood up at 5:40 pm this evening to finally go pee, after I'd sat down in my chair at 7:20 this morning, when I got back to the computer, I realized I'd forgotten to take my hourly breaks.  My eye doctor recommends every hour take two to five minutes to stare at something far away from me.  Ten feet, twenty feet, a half mile - anything further than the end of my arms (where I keep my three monitors) away from my eyeballs.  It took about five minutes for my eyes to refocus on the screens.  And since I keep the type fairly small to get as much information in front of me as possible so I can eliminate what I do not need, well, there's the problem.

So as a final warning, if I'm not here again for a few days/weeks, I'm drinking from the firehose again.  This is my sixth year-end/welcome season, my fifth as a semi-functional team member, so I guess I'm helpful.  I closed out 100 of those tasks today - that is, I determined of the long list that 100 in the two locations I'm responsible for are continuing, and got them approved, or not continuing, and closed them out.  I also confirmed that there are another 177 patients that I'm going to have to review - some on 12/31/2023, and some on 01/01/2024.  Oh, and to add to the fun and frolic?  Some of those organizations will tell me they can't look at a request that started yesterday - they have to start today.  But they were closed from the evening of 12/29 through - in some cases - the start of business on 01/03 - so what am I going to do about getting paid to keep our mutual customer alive?  Some of our organizations absolutely refused to even consider looking into January.  Possibly because they know the patient IS going to change insurance, or maybe they're just not even willing to look into their crystal ball and tell me they just haven't gotten all of those forms processed yet...  

But I guess the overtime is nice. . .  If you live to spend it.  Fingers crossed that I do.