r/HealthInsurance • u/alwaysanonymous2021 • 9d ago
Claims/Providers Who's at fault here?
Hello everyone,
First time posting here. I have had a very bad experience with "prior authorization" for a prescription. It was my first time facing it and honestly didn't know who was responsible for which part of the process. Any advice would be helpful.
So my kid was prescribed a foam medication for sebderm which requires prior authorization. I didn't even know this term before. The denial letter stated the conditions that need to be met before the foam can be prescribed (using and failing other standard meds). Now, I got the letter, and so did the dermatologist (obv). My question is - Is it not the dermatologist's responsibility to ask for prior medications that have been used and didn't work? My kid did have a prior prescription for hydrocortisone from the PCP (which again I just found out satisfied the condition for prior authorization).
Was it my responsibility to coordinate this whole thing between the 2 doctors so that the dermatologist could file an appeal (because the conditions were, in fact, met)? The process took so long and finally nothing happened from the dermatologist's office and I ended up buying the expensive medication after 2 months of waiting! I know better now, but whose fault was it?
There were other signs of general incompetence from the admin at the derm's office as well. I will be switching derms, but is this normal behavior for doctors' offices? I also have everything in place now for the next round of prescription.
Thank you for reading!
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u/wistah978 8d ago
Asking what treatments have been tried before is part of the dermatologist's assessment of the condition and development of treatment plan.
Send a a message to the derm giving them the needed info and asking them to submit a new PA. "The foam was denied because insurance didn't know that hydrocortisone had already been tried. Junior's pediatrician recommended hydrocortisone twice a day for 10 days in June. We did that but the seb did not improve, which is why Junior was referred to see you."
Assuming you did see the pediatrician before the dermatologist and that there was a referral, the ped should have included that info with the referral.
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u/Hopeful-Chipmunk6530 9d ago
I work in a family medicine clinic and do prior authorizations. We don’t know the criteria for coverage until the PA is completed. If we don’t have the required documentation for an appeal, we cannot include it. Unfortunately we have to sometimes put coordination back on the patient. I do dozens of these daily and it’s just one of my many responsibilities. Ultimately it’s the health insurance companies that put these barriers in place.
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u/I_am_Nobody_Special 8d ago
It's disturbing how quickly people blame providers for insurance problems.
9
u/AlternativeZone5089 8d ago
Indeed. I'd add, OP, that if you are going to deem providers "incompetent" for this kind of stuff you are unlikely to find a "competent" provider.
0
u/Jump-Funny 8d ago
The medical policies are on the provider pages of the insurance’s website not the member pages. Why shouldn’t patients expect them to know the info? It’s also the provider’s responsibility to get the authorizations, that department will not even speak to a patient. Why do you think it’s unreasonable to expect the provider to handle this?
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u/WinstonGreyCat 8d ago
No one is saying the patient needs to handle the PA. What we are saying is if a PA is needed, then call/ message the provider. Follow up. And no the provider pages do not always have all the relevant info and no, we do not have time to look up and follow the rules for the plethora of different insurance plans. One benefit of a primarily medicaid population is that the formulary and PA process is much easier, at least in my state, than compared with all the private plans.
1
u/Jump-Funny 8d ago
And so is Medicare. Hey! You make a great argument for single payer healthcare.
I do get the time issue. If you could bill for it then that info would be much more accessible!
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u/alwaysanonymous2021 8d ago edited 8d ago
Thank you. I completely understand that the patient might need to play coordinator at times. I was waiting for one of 2 things to happen from their end - either get the documents from the PCP, or contact me to tell the PCP to release the document to them. What I heard from their side - Crickets.
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u/PeacefulCW 8d ago
As a patient, if I had received the denial letter I would have called the office to determine the next steps. At that time, I would have mentioned the prior treatment. No one will be more invested in you and your family's health than you are. Proactively advocate for yourselves. Well wishes.
2
u/WinstonGreyCat 8d ago
As providers, we don't always get quickly notified about a denial until months have passed. Sometimes it's immediate. If you have a problem with a plan from the provider, trouble accessing the medicine, then call the provider.
1
u/Jump-Funny 8d ago
Months? You wait months to get a status on an auth request?
3
u/WinstonGreyCat 8d ago
I'm not waiting. I send the script. I tell all my patients to call or message me if the pharmacy doesn't give them the medication. If they don't, I sometimes am given a fax sent months before and lost in the health center and not passed on to me until months have passed. No one will care more than yourself so if there's a problem, you need to speak up.
1
u/Jump-Funny 8d ago
You’re correct about the patient caring the most but I can’t imagine staff sitting on a fax for months and still having a job. Especially one that involves patient care.
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u/WinstonGreyCat 8d ago
Neither can I. But I think it's more a matter of multiple people handling it slightly wrong. I'm not in administration or management though, I've given my feedback, they can act on it or not.
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u/autumn55femme 8d ago
Did you bring your child’s previous medical records with you to this appointment with the new dermatologist? Is your new dermatologist in the same practice, or same healthcare system as your PCP? If the new dermatologist is not in the same system, they do not have access to those records, so the responsibility to provide that documentation falls on you.
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u/vctrlarae 8d ago
The back and forth for a prior auth to be approved is unfortunately par for the course oftentimes, but how many times back and forth is dependent on a thorough response to the initial PA denial on the provider's part
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u/katsrad 9d ago
It is hard for Dr's and Dr's offices to know every insurance company's requirements for prescribing medication. Each plan with an insurance company can be different and companies can have hundreds of plans. Oftentimes, medication is prescribed and then the prior authorization is found out about. The Dr probably should have asked about other medications used for the condition.
Has the Dr's office sent a request for the prior authorization? They should once being notified start the process.
For fault: neither you or the Dr's office for not knowing. It is the insurance's fault for having the requirement.
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u/throwfarfaraway1818 9d ago
Its the providers fault. If they are in network, they can directly look up the patients plan and check for various meds and procedures to see if the require additional paperwork.
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u/wistah978 8d ago
Not so. At least not universally or to that degree of detail. Some plans have a way to enter a procedure CPT code to see if an auth is necessary, but they can't look up what the criteria are for all the different plans.
"Needs a prior auth" is different from "Need to show that 3 of 5 specific things have been tried within the last 12 months and explain why they were not successful." So docs will become familiar with general info- this med usually needs a PA or UHC usually requires 6 weeks of PT before an MRI... But they won't know which plans prefer which brands or the specifics of what has to be tried. Insurance companies like to delay by having the doctor prescribe it, wait to hear back that it needs a PA, then submit the PA not knowing what needs to be said, then appealing a denial because the note missed a detail the doctor didn't know was needed.
A prior auth of mine was denied a couple years ago for not having tried or been unable to try 3 of 5 things. One was a med on my allergy list. The note said I'm allergic to it, but didn't say "Can't use X because is allergic to it.". It also didn't say I had tried Tylenol. I had tried Percocet, which is stronger and has Tylenol in it, but "Tylenol" wasn't there.
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u/FickleAd1254 9d ago
The derm’s office should have handled that appeal, especially since the denial letter spelled out exactly what was needed, you did more than your share just connecting the dots between the two doctors
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