Another Way to Deny Health Coverage

Medication BottleMost people who have to take any prescription medication, or need certain imaging tests, that is covered through health insurance are familiar with the procedure of having to get prior authorization (a “PA number”) for the medication to be approved before it can be obtained at the pharmacy, or before the test can be done. Just a few years ago, this requirement was only requested for the most expensive medications or imaging studies. It is certainly understandable in those instances and which should be few in number enough that it is not too time consuming for physician offices to complete. Some companies make the process simpler than others and some make it completely ridiculous.

Because of the present, never-ending increase in the number of medications and procedures for which insurance companies want prior approval for patients, it has become nothing less than an aggravating intrusion into the physician-patient relationship. Insurance companies frequently will communicate to patients that the medication is waiting to get approval by the physician; I have always thought that is what giving a prescription is already. All of this is nothing more than an attempt to deny coverage for patients and then have a way to blame it on the physician. What the physician prescribed is what they approved, it is just not what the insurance company approved; that usually means that it isn’t cheap enough for them; quality is not the primary consideration.

At the beginning of every year, when patients are getting onto new Medicare Advantage health plans or their current plans have formulary changes, there is a barrage of wastefully sent letters wanting changes in medications that the patient is already taking or that are new. There are so many of these letters which come to physicians that many are thrown into the trash without even opening them. There is not enough healthcare staff in clinics to handle all of this mail which does nothing for patient care, but only serves to lower insurance company costs. If all of these changes in medications are saving insurance companies so much money, then it is not obviously making its way back to the patients; insurance rates and medication costs continue to climb.

To give an example, I have a patient just this last week in which it took ten days to get a generic medication approved for her. She has been on this hypertension medication for 2 and ½ years. This patient has to take five medications from different classes to control her blood pressure and she has a very limited income that makes it impossible for her to do much with her life that she would like. She has multiple medical problems and it took a long time to get her blood pressure controlled with the current regimen. A nephrologist has been in agreement with her medication regimen also as we tried to help her get controlled and finally achieved that with continual monitoring by the patient. Earlier this week, she was almost in tears and very anxious that she was going to have a stroke because her insurance company’s drug plan (a Medicare Advantage company) stated that her medication was being prescribed at a level that was not FDA approved, so they would not approve it. This medication was double the usual dosage, but it took that to get her controlled. Two physicians have agreed that this medication is needed, the patient is pleased that it is working, and there are no adverse effects. Despite attempts to get the insurance company to approve this, they kept denying coverage until, once again, I had to take more time to get on the telephone and request to speak with one of their physicians who could hopefully understand this and make an intelligent decision to approve this patient’s medication. She was down to the last day of the medication and could not afford to buy the medication herself, even though it is generic, because medications have been inflated in cost so much. After discussing this for quite a while and asking for a physician to call me, I went home late that evening and never did get a call until the next afternoon. However, the insurance company had sent another fax to the clinic that next morning and had reversed their denial already. I was left wondering why all of that was necessary to achieve what could be so simple.

The practice of medicine and provision of healthcare services must get back to what should be its mission: taking care of the patient. Thankfully, the Mississippi Legislature is in the process of doing something to help physicians and patients with the House already passing HB 301 which would simplify the prior approval process greatly in that there would be a requirement of using the same PA form for every insurance company which can be submitted online, can’t be longer than two pages, and would automatically grant approval if not answered within two days. Thank you to the MS Legislature for putting some common sense back into this process.


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