For the past 2 days, I've been on the phone with an insurance company every couple of hours trying to get a prior authorization approved as quickly as possible for one of our customers.
She's an elderly lady who happened to somehow develop C. diff as an outpatient. I didn't really check if she just had a course of antibiotics which could have precipitated the infection. All I know is that she has C. diff, and she's failed metronidazole. Therefore, the next option to treat it is oral vancomycin. However, oral vancomycin is very expensive. A 14 day course of it is over $1,000. For this reason, the insurance company wants to make absolutely sure that all other options have been exhausted.
Well, this has been going on for 2 days now. The doctor's office faxed in the prior authorization paper work.... twice. It was marked urgent. Still no approval. I called the insurance company, and found out that they still want some more info from the office before they'll approve it.
WHAT OTHER INFO COULD THEY POSSIBLY WANT?????? There should be 2 things the insurance company asks before filling this prescription: Does the patient have C. diff? (YES). Has the patient tried metronidazole? (YES!!!) If both answers are yes (as in this case), they should instantly approve it. It shouldn't take faxes back and forth. It should take one 2-minute phone call.
It's stuff like this that really gets to me because it shows that this business isn't really about healthcare. It's about the freaking money before anything else. The insurance company doesn't want to spend $1,000 on the oral vancomycin. Therefore, they'll try anything to not approve it. Of course, that makes no fucking sense therapeutically or financially because if she doesn't get this medication, there's a very strong chance that she'll end up in the hospital, and it's going to cost a HELL of a lot more money to hospitalize a patient than it will to just pay for those damn capsules.
What's going to end up happening is the patient is going to pay the $1,000 up front and hope that the insurance will eventually approve it, and we'll be able to reimburse her. It should never come down to that, but that's the nature of the profession. Fucking stupid.
Let me make one more point: I don't understand why everything has to be done via fax. Whatever happened to picking up the phone and actually speaking to someone about this stuff. If the doctor's office (the patient's healthcare provider) calls the insurance company and verbally explains the reason for using a particular medication, then it should be either approved or rejected right on the spot. Why do we neeed to waste time and paper by faxing things back and forth?
It goes to really ridiculous lengths. Let me walk you through the process:
First, I'll try processing the claim and get a prior authorization required rejection. I'll immediately call the doctor's office only to have some secretary tell me to fax the rejection and insurance info to the office, and then they'll take care of it.
Upon receiving my fax, the doctor's office will call the insurance company, who in turn, will them to fax the prior authorization request to them. Of course, in order to fax the request, the office needs a certain prior authorization request form from the insurance company, which they can only get by having the insurance company fax them a copy of the form (or by going online and printing them out).
After faxing the prior authorization request, the insurance company will review it. Sometimes, it'll decide that the information is incomplete. In this case, they'll fax the doctor's office asking them to fax more information to them.
Then, the doctor's office will fax the necessary information to the insurance company. The insurance company will review it, accept or reject it, and then fax their decision to the doctor's office, which may or may not decide to send a copy of that fax to our pharmacy, so that we are aware we can now fill the prescription.
All that time and all that paper is wasted when all it should take is 3 phone calls: One from the pharmacy to the doctor's office, one from the doctor's office to the insurance company, and one from the doctor's office back to us.
The whole faxing process is fucking stupid. For simple things like refill requests, I understand the simplicity of fax requests. For stuff that requires clinicial review, there should be an active discussion between physician and insurance company. You can't have a discussion via fax. It would be like making clinical decisions via text message. It's stupid.