Should PROBABLY Bite My Tongue...

 It's no secret - I work every day asking insurance companies to make a decision on whether or not a patient can receive a particular medication.

It's much more complicated than that, but the bottom line is simple.  A doctor meets with a patient, reviews their medical condition and history, and then uses their judgement to select from a growing field of medicine a particular medication that will treat the patient and improve their health.  Quite often it's not a cure, as most of the time these are conditions that don't have cures.  It's usually a treatment to help the patient feel and do better.  

The insurance company will tell you they aren't making care decisions, they're simply using their best medical judgement to determine whether the prescribed treatment is going to have a positive response.  Certainly, the medications are expensive, but they aren't fooling me.  The reviewer, who is also a trained medical professional, looks at the medical documentation we submit, and then uses their judgement to decide whether or not the treatment makes sense, meets their criteria, which means the patient has tried and failed or can't try certain alternatives, plus other details, some of which they do publish, and some that are, I am certain, are economic-based.

This week, a company I deal with regularly, Prime Therapeutics, issued a notice that in New York state, authorization requests may ONLY be submitted by the doctor or the doctor's staff, or the patient.  Oh, I get it.  PT doesn't like dealing with the riff-raff like me, people who have been doing this for a couple years now, who don't know the patient's condition, what the medication is supposed to do, or what the alternatives are.  

But I do think that PT is also a real piece of work.  Because in doing this job, I know an awful lot that doctors don't.  I know things like oh, hey, is this going to run through a patient's medical coverage or pharmacy coverage?  It's also possible that there are only certain pharmacies that will be able to order and deliver the medication to the patient.  Then there's the other questions like is this something the patient can do themselves?  With a little help from a family member?  Or do they require professional nursing help?  Do they have conditions in their homes that might present problems?  

I can't even begin to imaging the kind of problems this is going to create.  Doctor offices are busy places, where patient CARE comes first, not the annoying back-and-forth crap I have to deal with where I submit a request - does it have to be phoned in where I speak with a live human, or is it an AI that doesn't understand what I'm saying when I have to give it the drug name?  Or do I fax everything in after I download and partially complete a form that the doctor needs to finish and sign?  Or do I submit on-line?  After starting the request, I have to call two days later to make sure they have received the entire fax with the documents, and orders, do they need additional documentation?  How long is it going to take for them to make their decision?  Is it a firm time frame, or is it "as soon as we can"?  

And all of that is after you listen to or check the box that you read the disclaimer that tells you that authorization or certification is not a promise of payment, only a statement that they agree to review the bill, when it's submitted, and make sure that the patient received the medication, the medication was the same thing - dose and frequency, not just the name of the medication - and consider possibly paying the bill.  

It's a pretty sad admission by Prime Therapeutics, who are based literally within twenty miles of where I live, that they don't want to have to deal with people who know how to do this - they'd much rather take time from the doctors, the scarce resource in this system, and have them waste it by arguing with them.

I do need to admit a few other things.  I do know some people who have, and are still working for Prime.  I do think it's a rather strange admission that they don't want professionals like me saving the doctor's time.  I can only hope that a lot of doctors stop taking patients with Prime Therapeutics as the reviewers for their plans.