Preauthorization for prescriptions

September 6, 2012 9:04 AM

Any other recourse when physician still has not faxed prior authorization form to insurance company?

My husband was prescribed a medication the first week of August that requires his doctor to complete and fax a prior authorization form to the insurance company before he can fill the prescription. It's now five weeks later and this has still not been done. He has called the doctor's office several times, told that the doctor had "filled out half the form" but it stopped there, was told the doctor was "paged," etc.

If he fills the prescription without getting prior authorization, and we pay full price, will insurance companies penalize you in any way? Do we have any other recourse to get this prior authorization submitted? I've called and talked to Patient Services at the hospital, all they said was "we've contacted the doctor and were told it would happen shortly." It's very frustrating.

Has anyone else had to deal with this?

posted by anonymous to health & fitness (11 answers total)

I'm not sure what you could do other than getting a new physician, sounds like this one is a dawdler.

I'm assuming that getting a new prescription for the equivalent medication that would not require a prior auth is not something that would work for you? Typically if I write a script for something that needs a prior auth, the pharmacy calls me and I change it to the closest equivalent that the insurance co will cover. Then again I am an ER doc so I don't have to worry about faxing forms and all that.

I'm not aware of any penalty for paying full price yourself in any scenario, other than the pain of picturing the insurance company execs cackling evilly that they got out of paying what they should have had to pay. But I'll be interested to see if others have found any way around this.
posted by treehorn+bunny at 9:15 AM on September 6, 2012 [1 favorite]

Have you tried filling the prescription at the pharmacy? If you ask nicely, the pharmacist can probably call to obtain authorization. Sometimes a call from the pharmacist is the fastest way- they might even be able to get verbal authorization over the phone.
posted by abirae at 9:17 AM on September 6, 2012 [1 favorite]

Yes. I promised myself that once it got to the two week mark I would set up camp in their waiting room until I got the form taken care of. After having three pharmacies call and making five calls to the prescription refill line, it got done. The insurance company refuses to pay at a retail pharmacy, it's mail order or nothing, which I found out the hard way that month. Fun times.

I still have to order them up a month in advance and request a resend or two every time (it's all electronic now). I've built it into my schedule. "I've got six weeks left of this, it takes four to get a preauth/renewal done, so I should call today."

When we were dealing with ADHD meds, the refill had to be picked up monthly and called in advance (and was 20 miles away), but that office was awesome, they had a turn around of 1 day. Of course ADHD scripts aren't the "preauth forms" from hell, either. Same thing, reminder on the calendar for all followups.

As for the second part of the question - how much is the med? When the issue was insurance paying for a drug or not and it was under $150 (my comfort zone) I did (though they had to reissue some crap and it was funky with a refund from the drugstore). When it's the $2,000 a month stuff, I try to do with out - though the pharmacuetical industry does have a co-pay assistance plan that might have helped. Generics are usually in the "cheap" zone that I'll eat it if I have to. There's no cheap for some of the meds they charge $2000 for, though.
posted by tilde at 9:19 AM on September 6, 2012

Call the insurance company, explain your situation, ask about their policies for such situations. If they tell you anything which sounds good, like "oh, sure, we will happily reimburse you later", get them to fax you that info the same day and request a paper copy be mailed as well. Do not spend a dime (unless you are willing to eat the cost) until you have it "in writing" (via fax should be sufficient).

If they don't say anything wonderful like that, ask if it is possible for them to request the info from your doctor on your behalf. Doctors get the bulk of their income through insurance payments. They might be more attentive to the request should the people who keep their lights on do the talking.

I would probably also try showing up in person and, if possible, fill the form out myself so the doctor only needs to sign it then request ten seconds of their precious time so they can add their John Hancock. For their convenience, of course, since you understand how busy they are. (SMILE)
posted by Michele in California at 9:46 AM on September 6, 2012 [1 favorite]

2nding prescription assistance - a good pharmacist can make magic! I still fill my scripts at CVS just because I loved jessie, my old pharmacist at the CVS where I used to live - he managed to wrangle multiple discounts for drugs my insurance didn't cover, and would call my doctor as often as needed - he always went the extra mile, and was a badass pharmacy ninja. Maybe you can find a ninja like Jessie to help you out.
posted by abirae at 9:50 AM on September 6, 2012

Also economically, the insurance has the least incentive to help you out. They don't want to spend money if they can help it. The doctor is neutral on the money issue but busy with other things. Your pharmacy however wants to sell stuff. I don't think pharmacists directly profit from your prescriptions, but the store does, so as an institution, your drug store has the greatest incentive to help you out. Kind helpful people are gems when you find them, but when you can't, use capitalism to your advantage.
posted by abirae at 9:55 AM on September 6, 2012

Show up to the office and request they fax the form and rec confirmation.

If you pay for the pills; save the receipts. Ask the insurance to backdate your (assuming approved ) auth for the date you filled the RX. Most of the time pharmacy can reprocess if within a few days. If not ask your insurance to send forms for reimbursement but backdating the auth is important.

Also, complain to the phy board.
posted by Bun Surnt at 9:58 AM on September 6, 2012

Who have you talked to at the office? Is it just one doctor and a secretary, or a bigger office with lots of aides and assistants? If it's the latter, and you've only talked to the phone/scheduling people, see if you can talk to either his PA/tech/nurse/aide or his secretary. Get that person on your side and have him/her advocate for you. S/he may be able to fill out the form and then just have the doctor initial it.
posted by radioamy at 12:18 PM on September 6, 2012

From the OP:

Moments after posting this, my husband got a call from the doctor, finally. He submitted the form and even talked to a doctor at the health insurance company (this is called peer to peer, maybe?). Anyway the bad news is the insurance company is still viewing his condition as Issue A when the doctor has clearly diagnosed him as Issue B, which is medically necessary. It looks unlikely that the insurance company will change its mind (they said their doctor is reviewing and will get back to us in 7-10 days) because it is in their best interest - as always - to not cover it.

This is my first time dealing extensively with health insurance and health coverage and can I just say, if there is a more demoralizing and depressing thing than fighting with an insurance company, I haven't found it yet.

Thank you for your suggestions, everyone! I hope this question helps someone.

posted by mathowie at 12:45 PM on September 6, 2012

I would suggest to the OP and her husband that they join support groups online in whatever fashion works for you. Facebook has [$_illness] support groups, Twitter, bloggers, and so on.

For example, I've got friends who follow Rheumatoid Arthritis Warrior on Facebook, or her site, or through twitter, talking using #disease_name hash tags, for example.

Many folks with different, chronic or other (cancer) diseases have been through this and are twitting or blogging or fracebooking about it. I'd keep a bit of a log yourself (I do a little one every time the kids come down with something; but none of them have long-term illnesses) so you can spot the 'patterns' and deal with it/expect it.

Good luck.
posted by tilde at 12:58 PM on September 6, 2012

It looks unlikely that the insurance company will change its mind (they said their doctor is reviewing and will get back to us in 7-10 days) because it is in their best interest - as always - to not cover it.

Read your policy documents. It may be possible to get a second opinion and to appeal. There may be a time limit on the appeal.
posted by grouse at 2:14 PM on September 6, 2012