Insurance Denial

A week or so ago we talked about the “joys” of insurance companies requiring “preauthorization” for the use of medications. At the proverbial Bottom Line, we pondered the impact that delays and other short circuits could have on the quality of the medical care delivered.

Here we go again. This blog post by a “whistle blowing” physician considers this issue from the extreme case to the day-to-day. More specifically, it begins with the report of a jury awarding $25 Million to the family of a cancer patient that was denied access to a medication and later died.

At a more prosaic level, the article goes on to describe a “step therapy requirement,” that is not an absolute denial but rather will authorize a more expensive medication only if less expensive alternatives have failed. Got me to thinking. In virtually every study we do at ThinkGen, we hear physician reports of this requirement and the impact that it has on their practices. What impact? Oh, little things. Like hours of paperwork and the delay of the care which the doctor believes to be optimal.

In this latter regard, check out the blogging physician’s tongue in cheek speech that he would recommend that a doctor faced with this set of circumstances might give to the patient:

“I prescribed a medication to you that my training and experience informs me is the best choice for you. Instead, let’s spend the next few months giving you some different medicines, just for fun. I don’t think this medicine really makes sense in your case; that’s why I didn’t prescribe it. Your insurance company, who always has your health and welfare as its highest priority, want us to wander off course for a while. Who knows?  Miracles happen. Maybe the stuff might work by accident. No need to fret too much.  Eventually they will give in and you will ultimately get the right stuff covered. And think of all the quality time the two of us will enjoy on our journey together!”

Right on! 

Also, not to be ignored in his post are the blogger’s musings as to whether or not the real purpose of the step therapy requirement is to make doctors and patients give up and go away. Interesting and bothersome notion.

Bottom Line. Like we said at the conclusion of our last blog post on this topic, the unintended (and intended?) consequences of preauthorization and step therapy requirements are profound. Give them some thought, and figure out what you would do about all of this if you were a physician who was “Czar of all of Russia?” Or, the CEO of a medical insurance company that considers every dollar it spends on patient care to be a ding in their profitability?

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