The myth of prior authorization

by Richard S. Winer, M.D. | Medication, Psychiatry

Having been in the private practice of psychiatry for over 30 years, I am glad to say that I still very much enjoy providing direct care for my patients. With equal conviction, I can safely state that like most of us who work in health care I am not a big fan of all the paperwork that goes along with my practice. This is not to say that medical records don’t have a place in our work. But, the situation has mushroomed to the point that we are incredibly consumed by the avalanche of paperwork that can take up more time than what we provide for our patients. In recent years, the biggest and most increasing offender has been, in my opinion, the prior authorization process.

Quite simply, the prior authorization process has become the bane of our existence as clinicians. Perhaps you recall from past history classes that the Holy Roman Empire was not holy, Roman, or an empire. I used to think that informed consent was the Holy Roman Empire of medicine because it didn’t always seem informed and wasn’t necessarily consent. Now, I am increasingly convinced that prior authorization should join informed consent in that grouping.

Most often, we find out that a prior authorization is required after our patients go to pick up a prescription we have written or called in well prior to that time. As far as authorization goes, you sure can’t count on that happening even if the request is for a medication believed to be in the best interest of the patient. What I have seen take place under the guise of prior authorization at times appears to defy belief. To say this is frustrating for clinicians and patients alike is a huge understatement. Let’s go over some examples.

Twenty years ago, Congress enacted the Health Insurance Portability and Accountability Act, better known as HIPAA. While this was designed to help provide continuity in coverage to those who might have a change in insurance coverage as the result of a job change, there really is not much resembling portability when it comes to medications. When January rolls around, countless patients change their insurance sometimes by their own choice and other times because an employer has made a change for them.

Suddenly, the medications that have been effective for a considerable length of time now come under scrutiny by insurance and managed care companies because there is absolutely no uniformity in the formularies each insurance company maintains. I had one patient earlier this year who needed a prior authorization on a medication she had taken effectively nearly 30 years to help combat potential side effects from another medication that has been similarly helpful in treating her psychiatric condition. Mind you, this was not some incredibly expensive medication. The medication has been available in generic form for years, is not prescribed that frequently now, and almost assuredly would cost far less out-of-pocket than what it was costing the insurance company to process the so-called authorization in the first place.

Many of us in health care have been perplexed about coverage that is relatively decent if a patient requires hospitalization, but is downright lousy and often non-existent for treatment that can help prevent the far more expensive—in dollars, not to mention emotional and physical wear and tear—inpatient treatment that is covered. During the past several years, we have heard the term “too big to fail” in discussions about certain major financial institutions. Well, don’t tell that to the insurance carriers who actually require or seemingly want patients to fail on at least one and often at least two medications before considering approval of a medication that already has been helping a patient.

In my field, there are generic medications that a patient is required to try that could pose problems because of its “up and down” course of action, its decreased efficacy, its limited duration of action, or its abuse and dependence potential. That’s not such a great idea for patients who might already have a history of bipolar disorder or seizure disorder and would likely do better on a smoother medication. It’s not a very good idea either for patients who because of their condition or their lifestyle and work pattern are going to be more prone to forgetting to take additional doses during the day when a once daily medication is available and effective. It’s also problematic for a patient actively abusing substances.

Some of the branded products have actually been around several years and have proven to be very beneficial for a substantial number of patients. Granted, some of those medications can be quite expensive. However, if they work well and don’t have to be taken as many times a day as some of the generics, there is a potential benefit to a patient being more productive and an insurance company spending less money overall on medication.

Jumping through all of these hoops reminds me of some circus acts, but those are displays of skill and they are considered entertainment. There is nothing skillful about jumping through the hoops to get a medication approved unless you develop a skill in how to play this game. Regardless, it’s sure not entertaining. For example, there have been numerous times when a request for a prior authorization has been declined because the patient has not tried certain other meds. Imagine the bewilderment I have experienced when the attempt to try one of those other suggested meds was foiled because that recommended medication also was not on the approved list and required a prior authorization as well. This should help give you an idea why it is easy to feel that we are practicing medicine with one hand tied behind our backs.

When we find out that a medication will require a prior authorization, the fun is only just beginning. Typically, I find out that this exercise is needed either when a patient calls the office to notify me or when a pharmacy sends me a fax to let me know what happens next. That fax most often includes a phone number to call to initiate the prior authorization along with the patient’s identification number. Here’s the catch. At best, it is even money that the phone number provided will actually be the correct one and just slightly better that the patient number will be correct. I am not exaggerating when I point out that I could be passed along to four or five numbers and people before I might actually come upon the right person.

Each time, the person at the other end of the line would ask for my name, NPI number, phone number, and fax number. Then, that same person would ask for all the pertinent information about the patient. With any luck, the next question would be whether I wanted the prior authorization form faxed to me or if I wanted to answer the questions on the phone. By now, I am so worn down and numb by the experience it is hard to say which way I want to proceed. If I elect to handle things over the phone, there are times when I am only asked to confirm the diagnosis.

Going on that scavenger hunt also has its limitations–that is, time limitations. I have often commented that when I decided to go into psychiatry, there were those who told me I would have banker’s hours. Little did I know that I was more likely to have the 24/7 hours of the ATM. Calling for a prior authorization often would take place after I finished seeing my last patient of the day. Unfortunately, that did not coincide with the hours of many of the companies I was supposed to call. Many of them were closed by 5 or 6 pm.

Those prior authorization forms are something else. The forms are often pre-printed with the name and birth date of the patient. Yet, the first question on the form is frequently, believe it or not, “What is the patient’s age?” After already providing information about being in psychiatry, I will then receive a form that asks if a mental health specialist has been involved in the diagnosis and/or treatment of the patient in question.

Some forms only have one or two questions to answer. When those forms are finally sent in, there is only a temporary sense of relief. It is not a permanent relief because there is still the likelihood that a patient’s employer and insurance coverage will require some additional questions to be answered. When all is said and done, it is possible I will have filled out three prior authorization forms to maybe accomplish success in getting a medication approved for my patient.

In a recent development, a prior authorization form was filled out and turned in. Much to my relief, an approval was granted. Unfortunately, the approval was given for the wrong patient with the same last name although the patient’s ID number was that of my patient. Please trust me when I say that the patient’s last name was not Smith or Jones. The prior authorization had to be turned in yet again.

In the event the prior authorization request goes through, there are additional obstacles that just might remain. On average, the approval is good for one year. That means the process has to be done all over again in a year—that is, unless the insurance coverage changes again in less than a year. In all fairness, there are occasions when the approval is granted for as many of five years. It is equally fair to state that are numerous times when approval is given for less than a year.

In one of my most recent experiences obtaining a prior authorization, I spent 20 minutes on the phone and ultimately had to answer only three clinical questions. The result: my patient was approved for her medication for a grand total of the next 30 days. If that sounds bizarre, then there is no telling what you might think when I point out that the medication was also approved for the 30 days before the prescription was ever called in to the pharmacy.

The success of a new medication is commonly the result of careful titration to the optimal dose for a patient. The motto of “Start slow and go slow” makes a lot of sense as we want our patients to initially tolerate the medication before we advance to the most efficacious dose. This means that many of my patients—particularly those who take medication that comes in a capsule—need to start at one dose and perhaps 7-10 days later move up to another dose.

Many insurance plans insist on separate prior authorizations for each dose the patient might end up taking. Incredibly, there are times when one dose is approved, but a different dose does not pass the test.

The patient’s age can make a huge difference in the prior authorization process. Some requests are denied because the patient is past age 18 or 19 even though the medication is actually indicated for patients six years old and up. More confounding is the fact that a medication might be all right for someone 17 years old, but then becomes unacceptable by virtue of that teenager turning 18 years old. I don’t know of any medication that suddenly becomes unnecessary because someone has just become eligible to vote.

Those are some of the complications that can still occur with an approval. That doesn’t even account for the quantity exceptions we go through because a medication needs to be taken more frequently. What happens when we decide to appeal an adverse decision is often nothing short of the theatre of the absurd. Our patients have a very hard time understanding why a prior authorization request can take days before a response is forthcoming. They would like to think that if a prescription is provided, they should be able to get it filled quickly. The appeals can take much more time.

Some companies require that an appeal be made in writing while others allow the clinician to either fax or call to leave added information. That only adds to the excruciating delay for a patient to find out if the prescribed medication may be taken. The appeal process can allow for what is loosely termed a “peer-to-peer” review. When I have done peer reviews for patients with disability claims, more often than not I will speak with someone in other mental health disciplines than psychiatry.

The odds of speaking with a medical director about a psychiatric medication who also is a peer in the same field is slim. To the best of my recollection, I can only think of one time when I actually spoke with a colleague who happened to be a psychiatrist. This is not all that surprising because the physician or non-physician can simply play it by the book as it has been written by the company that has hired him or her. That book does not take into consideration the individual situation of a particular patient or the knowledge that a clinician has gained in working with that patient.

In recent days, I left a message for a medical director with information that might be helpful during the appeal process. This information included results from psychogenomic testing that is relatively new, but has become increasingly useful in guiding us toward or away from certain medications because of the individual’s genotype. On the return message, I was informed that the insurance company does not recognize results from this testing. Even Medicare has given the green light to cover the testing with no co-pay for those patients who carry a depression diagnosis.

There have been some attempts to streamline this incredibly awkward and time-consuming process by trying to handle requests electronically or obtaining forms without being put on interminable hold. But, this all takes time, too, and sometimes lots of it.

I have long been a sports fan and it has been said that baseball has tremendous appeal because it is timeless. However, baseball has come under criticism because the games take too long to play and the sport could lose some of its appeal. But, baseball is a game. The prior authorization process has all too often become timeless and that’s not counting the appeal when a request has been denied.

Unlike baseball, we are dealing with human beings who are looking to us to try to help them deal with struggles in their lives and time is of the essence. Baseball players wear uniforms; our patients can benefit from uniformity in handling medication requests. If a player goes from one team to another, the player’s records don’t start all over again. If our patients go from one coverage plan to another, they should not have to start all over with their treatment. That’s just good medicine.

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