Please indulge me in a little rant, in what I am calling, Savvy? NO!
This one is about prior authorizations that are increasingly required by our insurance companies before they agree to fill prescriptions or authorize payment for procedures.
Here is Wikipedia’s definition of Prior Authorization: Prior authorization is a check run by some insurance companies or third party payers before they will agree to cover certain prescribed medications or medical procedures. There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go through a separate process known as “step therapy” or “fail first”. Step therapy dictates that a patient must first see unsuccessful results from a medication or service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different service
The process is intended to act as a safety and cost-saving measure, although it has received criticism from physicians (and patients, emphasis mine) for being costly and time-consuming.
I trust my medical professionals to prescribe the best medications and order the necessary tests for my condition. When my endocrinologist (or any other hcp) writes an order, the very last thing I need is for my insurance company to DENY me or require my doctor and his staff to take precious time out of their day helping patients to JUSTIFY their choice of treatment. My doctor is my doctor, not some insurance agent!
It is an outrageous overstepping of their role, trying to usurp the ability of my doctor to provide care and treatment for me.
And while I’m at it, someone needs to take a look at the insurance personnel who decide which medications are eligible on their formulary. No doubt, they “prefer” medications for which they pay the least. But that doesn’t equate to the best medication for the patient!
Insurance reform, anyone???
Got any opinions? Please comment!
I call it the built in speedbump. In the end, I have never had one of these medications declined. What I think it does is remind doctors that if they prescribe certain treatments then they will spend more time and time means less reimbursement. The phrase, pay the price for prescribing the wrong medications. Something to think about.
Thanks Rick. I actually have had meds denied … they just decided that it won’t be on their formulary … so there! While I think doctors are in part at fault as they got a lot of perks from reps to sway them. But I still believe that my doctor has done enough research to prescribe what’s best for me.
I did mean to be cavalier in my response. I agree with you that doctors knwo way more than insurance companies. I was really speaking more tongue in check about the speed bump. The craziness of this health insurance system is the influences which impact our health care, and we do not even know what they are. The company rebates to PBM’s to influence placement on a formulary just exemplifies how bad the system is broken. In a way the patient pays twice. Once in increased medication pricing, Then with increased health premiums when the PBM’s do not give those rebates to the plans and then charge the plans for the service of the PBM. It is boggles my mind how this is allowed to keep going.
I totally understood your first comment and totally agree with everything you have written. “Boggles” is a good word for it … possibly “rage” or “outrage” too?!