Playing Poker With the Devil: “Prior Authorizations” are Paralyzing Patients and Burning out Providers

The faxes keep coming in, sometimes several at a time. “Your (Medicare) patient has received a temporary supply, but the drug you prescribed is not on our formulary or the dose is exceeding our limits.”

Well, which is it? Nine times out of ten, the fax doesn’t say. They don’t explain what their dosage limits are. And if it isn’t a covered drug, the covered alternatives are usually not listed.

So the insurance company is hoping for one of a few possible reactions to their fax: The patient gives up, the doctor tries but fails in getting approval, or the doctor doesn’t even try. In either case, the insurance company doesn’t pay for the drug, keeps their premium and pays their CEO a bigger bonus.

First problem: This may be in regards to a medication that costs less than a medium sized pizza. And the pharmacy generally doesn’t even bother telling the patient what the cash price is.

Second problem: A primary care physician’s time is worth $7 per minute (we need to generate $400/hour). We could spend half an hour or all day on a prior authorization and there is absolutely zero reimbursement for it.

In my opinion it is unconscionable for an insurer to say a drug isn’t covered without listing the covered alternatives. They are truly making us play a game where only they know the rules – and I have seen some of them change the rules mid-game.

EMRs sometimes have functional formulary checkers built in, but they don’t always work.

There are too many insurance companies for a provider to separately check their websites before prescribing.

There is an app called Epocrates that has many formularies built in. I have it set to Mainecare, the Maine version of Medicaid. But far from all insurers are included, plus some insurers have lots of different formularies.

All I know is I’m playing prescriber without knowing the rules of the game.

It is a pathetic state of affairs. The technology is out there but it isn’t in the interest of the for profit insurance companies to use it.

This alone is a reason to consider a one payer system: Mainecare publishes their formulary with real time updates and shares it with Epocrates. Their step care rules are easy to understand for both prescribers and patients.

Prior Authorization requirements are mostly meant to save insurers money, but sometimes they are efforts to control provider behavior. But we have the medical license and bear the liability burden when we prescribe. And the insurance companies don’t seem to have any legal risk when they refuse to honor our prescriptions and leave patients without treatment.

This situation is pure evil. I don’t think my analogy of playing poker with the devil is exaggerated at all. It is provider harassment and customer abuse.