why wouldn't my doctor provide a prior authorization?

November 8, 2022 10:13 AM

I was prescribed a new medication and my insurance company requires a prior authorization from my doctor. Her nurse just called and said that my doctor probably won't do that and instead will look for a similar medication that my insurance will cover without a prior authorization. I'm a little confused.

In the past when I have had insurance companies request a prior auth, my provider (usually my psychiatrist) had to fill out a form and submit it to the insurance company. Yes, it's extra paperwork and delays the prescription being filled, but then I at least get the medication my doctor has decided is appropriate for me.

This time it's my endocrinologist who needs to provide the prior auth. I have been seeing her for years, but she is taking me off Metformin because my body literally cannot handle the side effects anymore (after 21 years on Metformin I NEVER stopped having GI side effects) and instead has put me on something she thinks my stomach will tolerate better. So... why not just do the prior auth?

This message was conveyed to me by my endocrinologist's nurse and she wasn't able to give me a clear reason why the doctor wouldn't do a prior auth - just that she generally doesn't do them. I'm not going to call them back and go full Karen demanding to know why/demanding she do it; maybe there are other medication options that won't require a prior auth. I don't care honestly - I just have to get off of the bloody Metformin because it's seriously impeding my quality of life.

But I'm just curious if anyone out there knows why a doctor just wouldn't do prior auths for insurance companies seemingly on principle? Is there some behind-the-scenes info about prior auths that I am not privvy to? Is this endocrinology-specific?

Any insights or thoughts welcome, especially from doctors! Thanks!

posted by nayantara to Health & Fitness (21 answers total)

Most likely a combination of it is a large hassle, she isn't reimbursed for that time, she thinks the alternative is almost as good, and her past experiences with submitting them has been that they've been rejected anyway.

Submitting them remotely efficiently is a skill, perhaps one she never learned.
posted by Easy problem of consciousness at 10:25 AM on November 8, 2022 [8 favorites]

I will be interested to hear from doctors, but I just had one flat out refuse to do a prior authorization because they’re too time consuming. It was for a prescription that my insurance would cover with one, so now I just have to pay out of pocket. I couldn’t believe it.
posted by HotToddy at 10:27 AM on November 8, 2022 [8 favorites]

I am not a doctor, but I have been through this as a patient. My understanging is that getting a prior auth means the doctor has to call in, make a case for the treatment, insurance says no, they call back and escalate the request, insurance still says no, and then repeat until they say yes, the doctor gives up, or the patient gets worse/dies (not a joke, this happens.)

It is a pain in the neck and doctors literally have to be on the phone all day about it. Some people block out a whole working day to handle prior auths that they can't avoid requesting.
posted by blnkfrnk at 10:30 AM on November 8, 2022 [5 favorites]

Best answer: They are extremely time-consuming. I am fortunate in that I am only 50% clinical, in a field that doesn't have a ton of prior auths, AND because I work in an academic medical center, I have a staff of eight to handle most of the paperwork for me. (Not 8 for me specifically, 8 to support our department of about 70 "full-time equivalent" clinicians.) I still spend maybe 30-40 min per day reviewing/signing off on paperwork and appeal letters.

If the appeal letter doesn't work, I have to set up a "peer to peer" where I have to sit by the phone for a chunk of time (like waiting for appliance delivery) and plead the patient's case to an insurance company shill. The last time I did one of these, the person on the other end had never heard of levodopa, Parkinson's disease, or the FDA.
posted by basalganglia at 10:44 AM on November 8, 2022 [57 favorites]

I’ve never had a doctor refuse to try, but quite often it takes a week or more before they can get it done. A number of times, the insurance has still denied it after the doctor had done everything they could, and the doctor ended up prescribing the second-choice drug instead. IANAD, IANYD, but it’s easy for me to imagine a scenario where the doctor decides it’s better to just proceed directly to the second-choice drug if it’s nearly as good as the first choice.

The endocrinologist I saw for over 20 years (who just retired, and I’m starting with a new doc this month, gulp) had a full-time staff member whose job was just to deal with insurance paperwork.
posted by The Underpants Monster at 10:58 AM on November 8, 2022

Your doctor is doing you a favor. Finding a drug that will work just as well and won't require pre-authorization will get you the treatment you need more quickly.
posted by jesourie at 11:12 AM on November 8, 2022 [4 favorites]

My doctor has had to submit a prior authorization on my behalf. When insurance declined to cover the drug, he had to do a one-one-one call with someone explaining why I need this particular drug. He handled it very quickly and I’m sure he’s been through it countless times but as a lay person, I can empathize with someone not wanting to do any of that.

Moreover, when my doctor filled out a form related to this drug, he had to state that I’d tried similar drugs before and stopped taking them because they didn’t work or because the side effects were too much. If there’s a similar drug you can try first, it’s probably preferable from the doctor’s perspective that you try that. If it works, great! If not, that makes a stronger case for trying the drug your doctor initially prescribed.

Sorry you’re dealing with this but this sounds like a hiccup. I hope you have what you need soon.
posted by kat518 at 11:16 AM on November 8, 2022

If the appeal letter doesn't work, I have to set up a "peer to peer" where I have to sit by the phone for a chunk of time (like waiting for appliance delivery) and plead the patient's case to an insurance company shill.

I was *livid* on my doctor’s behalf that he had to do one of these for me for a drug he’s been prescribing and I’ve been taking for years. Thanks for doing right by your patients.
posted by kat518 at 11:22 AM on November 8, 2022 [18 favorites]

Best answer: There are very few diabetes medications where there is only one drug in the class, ie where there are no equivalent alternatives (Metformin is the only one I can think of, actually!). So it's probably the case that rather than plead a case that you absolutely need, for example, specifically semaglutide, your doctor is just going to prescribe the similar-but-different liraglutide that your insurance company would rather pay for.

In my field (pulmonary medicine) there are multiple brands and formulations of what are essentially the same inhalers; no study has ever shown that one of the same "category" of inhaler is better than any other, so I always tell my patients that I have attempted to prescribe the one their insurance wants to pay for, but if their insurance company pushes back we'll switch to whichever one they prefer.

I still do lots of prior auths (and they are incredibly unpleasant), but those are reasons why I often don't bother.
posted by telegraph at 11:35 AM on November 8, 2022 [8 favorites]

There is an everpresent danger that insurance networks will drop doctors who cost them too much, and doctors who are not part of larger institutions don’t have much leverage against insurers.

Requiring prior authorization constitutes a warning to your doctor that the insurer is not happy with the prescription, and it’s understandable that your doctor might be reluctant to cross that line absent dire necessity.
posted by jamjam at 12:51 PM on November 8, 2022

My partner had a doctor who really really didn’t want to do prior auths for all the reasons given above plus he was just absolutely furious at the insurance company for being jerks about this med situation. He was perfectly happy to keep my partner fully stocked with his very expensive medication purely on free samples, pretty much forever, rather than do the auth.

I recently spoke to a doctor about a new script for myself, right at the time I was considering changing jobs. She went from very enthusiastic about a particular med to really down on it the second she heard what insurance I had, because her luck getting prior auths with that particular insurance for this med is terrible. It wasn’t urgent so we agreed to wait until I decided about the job so she wouldn’t have to do it twice in short order. She clearly had some very specific experience to draw on re: the combination of med and insurer that made her hesitant in that case when she’s not down on prior auths in general.
posted by Stacey at 1:49 PM on November 8, 2022 [3 favorites]

Best answer: And get ready for Jan 1, 2023, when lots of insurers change their "formulary" and drugs that were tier 1 and did not require a prior auth suddenly change tiers, and now must not only be prior authed, but have a higher co-pay or require a documented trial of a tier 1 med. This is a typical insurance racket, and the same thing happens if you change insurers mid-year. There is almost no way to game this system, for patients or providers (who have to know what the typical insurance companies in the region allow when they prescribe to lessen rejections.)

If it's a truly essential medication most doctors will do whatever it takes to get the patient access, including escalating to peer-to-peer consults and beyond, which I've seen a couple of times, but in cases where there are alternatives it really does make sense to try the alternatives first.

Stacey mentions above that her partner's doctor provided samples, but fewer and fewer doctors accept samples after the pharma/doc kickback scandals of the early 2000s. Lots of academic practices now refuse to carry samples.
posted by citygirl at 2:04 PM on November 8, 2022 [3 favorites]

Best answer: I just wrote and deleted an absurdly long rant about how bad PA's are. TLDR: The "extra paperwork" you mention can translate to dozens of hours of (unreimbursed) doctor/nurse/admin staff time. "delays the prescription being filled" can translate to many months of waiting, for an uncertain outcome. If your doctor spends the hours and $$$$ and manages to finally get a peer to peer review, the "peer" might be a non endocrinologist who has never heard of your condition or the drug in question and just regurgitates the company line.
posted by mrgoldenbrown at 2:46 PM on November 8, 2022 [5 favorites]

I agree, your doctor is probably doing you, and themselves, a favor. In my experience with a certain medication, I needed prior authorization EVERY SINGLE TIME the prescription was refilled. Not only was the whole effort tiresome after awhile, but I had to buy an OTC substitute to cover the gap between when the medication ran out and when the insurance came through.
posted by Stuka at 3:13 PM on November 8, 2022

Anything is possible. Seirously.

I had a presciption delayed for about 4 months as I went back & forth with the doctor and pharmacy and it kept "getting rejected". Finally spoke to the right human person who said "oh, your insurance has rejected it, it needs Pre-Auth" so back to the doctor I went, who did a pre-auth.

Damned if I didn't get a nasty letter from the insurance company the next week, saying basically "This medicine is in the formulary and how dare you or your doctor submit a pre-auth - the nerve!"

It was for a 90 day supply, so I'm guessing I have 3 months until the fun resumes.
posted by soylent00FF00 at 4:11 PM on November 8, 2022 [1 favorite]

Best answer: I fkn hate doing prior authorizations but will do them when I truly feel that the desired medication is better than all other medications.

However, the current most common PA-requiring diabetes medications are the SGLT-2 inhibitors and the GLP-1 agonists. Each of those categories contains several medications and they all work about the same for diabetes. (Weight loss is a different story). It's hard to keep track of the insurance formulary coverage for all of those medications so my standard approach is to try to prescribe one, usually the one with the widest coverage. If it generates a PA, you can then look up the formulary to see which medications in that class ARE covered, or try something else. Sometimes you run into a situation where none of the medications in a particular category are covered, or the patient has to fail some other medication category first, and then it can be a real pain in the neck, but usually just switching to a different brand does the trick.

What the nurse is probably referring to about not doing PAs is that, if the doc prescribed ertugliflozin but it turns out that empagliflozin is on the formulary, the doc is probably not going to go to the mat for ertugliflozin right away because they work about the same and it's reasonable to try the one with coverage before fighting for one that's not covered.
posted by The Elusive Architeuthis at 5:24 PM on November 8, 2022 [4 favorites]

I at least get the medication my doctor has decided is appropriate for me.

One thing to remember, sometimes there is more than one right answer when it comes to medications. So if there are two or more medications that she thinks are likely to work and she hits a road block with one, switching out to something else without the roadblock and is likely to have the same outcome medically while also saving you and her a bunch of time and headaches. Especially since prior auth isn't always a one and done. As noted above, sometimes prior auths will be a recurring headache.

FWIW, I've had a doctor switch me to an OTC medication when she found out the prescribed version was no longer covered by my insurance. She explained to me that there were pros and cons to both versions, and she had mainly picked the prescribed one because she thought it would save me money. It's not precisely the same situation, but the underlying idea that there are multiple right answers is the same.
posted by ghost phoneme at 5:31 PM on November 8, 2022 [1 favorite]

I used to take a medication that required pre-authorization. And not just once: every time I needed a refill. It was not only a headache for my doctor, but also for me, because I had to submit it and be rejected (the insurance company wouldn't admit they required pre-authorization, even though they definitely did and always had), and we couldn't submit it early, so there was always a few days when I was down to just a couple of doses left and got anxious that I'd run out before all the bureaucratic BS was completed. My life became measurably better when I switched to a medication that is on the formulary, just because filling the prescription wasn't A Thing In My Life every 30 days.

So yeah, I think your doctor might be doing you a favor. But it's also worth asking whether the doctor really thinks the alternative drug is just as good. My doctor told me, basically, the two drugs he was choosing between were virtually identical, in his judgment, in terms of the likelihood they'd fix the problem we were trying to fix, and he had chosen based on what he uses most often, but that there was zero reason not to switch to save us both the hassle, and that he could have just as easily flipped a coin and prescribed the other one to start off with, and would have if he'd known it was on the formulary.
posted by decathecting at 7:21 PM on November 8, 2022 [1 favorite]

Response by poster: Thanks all! This has been super-enlightening (and super-depressing - basalganglia, the insurance company person you spoke to had never heard of the FDA?!! I don't even know what to do with that).

Looks like I'm being put on another med temporarily while they try to go to the mat with the prior auth on the originally prescribed med, but if the temp med works, then we'll stick with it. Either way, today was my last day taking Metformin! Hallelujah. My stomach and I are thrilled.

In conclusion, baby steps have been made, I learned a lot today from you all, and good god our medical system here in the US is a fucking disaster.
posted by nayantara at 7:52 PM on November 8, 2022 [3 favorites]

Best answer: Finding a drug that will work just as well and won't require pre-authorization will get you the treatment you need more quickly.

There’s also a cost savings on your part. Meds that require PAs are quite often only minimally “covered” by insurance. Much of the time, the patient will end up spending something close to full retail on a PA med, with only a minor piece paid by the insurer.
posted by Thorzdad at 5:08 AM on November 9, 2022

Best answer: For the insurance company, making it difficult for the doctor is a feature, not a bug. When there is a class of highly similar drugs, they put the cheapest they can get away with in their formulary, and make the more expensive ones ones harder to get. Citygirl described this above. They use higher co-pays, prior authorizations this way. The most common thing is moving to people off the brand name when a generic becomes available.
posted by SemiSalt at 5:08 AM on November 9, 2022 [3 favorites]