One physician’s creative response to bureaucratic frustration

A few days ago, one irate physician spent hours on the phone with a pharmacy benefit program. He was trying to get a prescription covered for his patient…that she was already on. What follows is the complete text of the actual letter (and bill for consultation) he mailed them. It is a glorious stance against bureaucracy.

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My dear fellow people who may someday need health care:

I am writing today to express my dismay and boundless frustration at your “prior authorization” process.

By way of introduction, I am a board-certified sleep disorders specialist, practicing in an academic sleep disorders center with full accreditation from the American Academy of Sleep Medicine.  All of this is relevant background, because most of the medications I prescribe end up in the vile netherterritory of “requiring prior authorization” when it comes to commercial medication management systems like ExpressScripts.  I therefore have had numerous interactions with your company, and today I had an experience which deserves telling.

Today, I received an email from the father of a patient of mine whom I’ll call Jane (not her real name).  She is a young woman, whom I diagnosed with idiopathic CNS hypersomnia back in October 2010.  For those of you reading this letter who may be unfamiliar with this diagnosis, idiopathic CNS hypersomnia is a disorder of the central nervous system, in which the patient feels impossibly sleepy, all the time, and no amount of sleep at night can fix it.  It leads to intense psychosocial dysfunction, poor work performance, and, sometimes causes people to crash cars.  Many cases don’t respond very well to stimulant medication, but, fortunately, Jane’s did.

At any rate, this is what the email said:

Dr. McCarty,

This is Bill Jones, Jane’s dad. Because of her heavy workload, I was asked to email you with a request. James, the Sam’s Club Pharmacist is having trouble getting Jane’s prescription for provigil processed and approved. She is having to buy one pill at a time out of her pocket until her new insurance gets what they need for approval. He said the doctor’s office needs to call this number ESI 1-800-235-4357  for prior authorization for this prescription. If there is anything you can do to help Jane with this, it would be greatly appreciated.   My wife and I appreciate everything you do for Jane.  If you have any questions or need to talk to me, please call.

Thanks again,

Bill Jones

At this point, I should mention that, since Jane’s diagnosis, she has been managed with low-dose modafinil, 100mg twice daily.  I suppose it goes without saying (after all, I’m a sleep disorders specialist) but I should mention that this diagnosis was made by me, in my sleep disorders center, in my lab, under my supervision.  So when I initiated therapy on this patient back in 2010, I recall answering the questions required for “preauthorization” and feeling they were quite straightforward:  I was asked her diagnosis (I told them); I was asked if the diagnosis was made by a sleep disorders specialist (check!) and I was informed that the drug was approved for a year.

This is where the trouble starts.  Since that time, I have had to undergo the same drill for this patient every year.  And every year, the questions and answers are the same.  This year was no different, but the weight of this process became achingly clear.

Today I called the number which was provided.  After multiple computer-generated menu-choices, I was placed on hold for a full 25 minutes.  When I finally spoke to a very nice young lady named Linda, she apologized for the long wait time, checked her file, and apologized because the number I really needed to call was 866-310-3666.  I was then transferred to that number, where I was then subjected to a whopping 50-minute hold time, before I could get through to a live person, to complete the “pre-authorization.” This is a short digression, but pre-authorization is imperfectly named, don’t you think?  It was pre-authorized back in 2010.  At this point, we are now well into re-authorizing, I would say.  Which, by the way, is just another way of saying we are re-doing something that doesn’t need to be done.  It’s redundant.  Doing the same thing over and over.  Repetitive.  (Annoying, isn’t it?).

Now, I hope you’re still paying attention, because here is the best part:   At this point, after having spent an hour and fifteen minutes of my day on the phone ON HOLD with your company, I was asked the same two questions that I answered, way back in 2010:

(1)  What is the diagnosis for which the prescription is being written?

and

(2) Was this diagnosis made by a Sleep Disorders specialist? 

OK.  Hold on.  You may have a hard time believing this part, so I’m asking now for the faint of heart among you to take a seat:

The answers were the same as they were back in 2010!

Holy smokes!  Who could’ve predicted it?

Now, if I didn’t know better, I would think that your company is deliberately setting up roadblocks to provision of covered services, because you know, deep down, that some of us doctors are just too busy, angry, drunk, or burned-out to stay on the phone for an hour and fifteen minutes to get “authorization” for a drug that has already been authorized in the past.  But nope!  You guessed wrong in my case.  Not me.  The longer you kept me on hold, the more determined I became to not let my patient down.  I knew that if I hung up,

(a)  my patient would be left in the lurch, spending her money on a service that you promised to cover as part of her contract with you (UNFAIR!)

and

(b) I would have to start the whole thing over and call you back (INCONVENIENT!)

So I hung in there, and eventually I was able to talk to a charming young woman in Saint Louis who secured the approval for Jane’s modafinil.  For a year.

So I did it.  I did it.  I gave you the consultation you needed, to make sure that this was still the right drug for this patient.  I provided the assurance you needed that this drug continues to be safe and medically necessary.

Don’t get me wrong:  I fully accept the proposal that you, Express Scripts* (NB: by the way, it’s charming how the name you chose implies speediness of service!  George Orwell could not have done so well!) should exercise some control over the prescribing habits of practicing physicians.  I agree that it is in your mandate to help control costs.  If part of this mandate requires “checking” with doctors again, to make sure that the diagnosis is correct, I agree, you should have this avenue available to you.  But this, my good people, will come at a price. It should be part of your cost of doing business.  I am happy to offer my professional consultative services in this capacity, and I will continue to do so at my standard hourly professional consultative rate.

Therefore, for the time that I spent on the telephone, waiting for you to get accept my call to obtain my professional consultation regarding the necessity of this medication, (a consultation you deemed necessary prior to allowing my patient to have access to a medically necessary prescription which is fully covered under her insurance for her indication), I have submitted a bill, for which I expect payment in full (attachment, below).  For new prescriptions (ie: those for which you do not have any clinical information at all), I will, in the future, waive this consultation fee, but for subsequent consultations (if the information has not changed) I will plan to do the same.

In the future, I would suggest that you consider the following:

  1. Create an allowance for diagnoses that are durable/unlikely to change with time, and allow longer authorization periods.  For a diagnosis such as idiopathic hypersomnia, I would use 5 or even 10 years.  Other diagnoses (such as narcolepsy) are lifelong.  By authorizing for five years at a time, you will be able to decrease your consultation fees with me by a whopping 500%!
  2. Create a telephone system that allows a single number to achieve service. This will allow shorter hold times, and also will reduce your consultation fees.
  3. For specialty medications, keep a roster of physicians who, like myself, specialize in the field for which the medication is being prescribed, and cut us some slack.  This may cut out a large majority of your consultation fees.  This element may require some explanation, because I don’t want to come off as an arrogant jerk (I’m actually a very down-to-earth and likeable person!), but, when it comes right down to it, I know what I’m talking about, and if I say a patient needs a medication, it’s because that patient NEEDS THAT MEDICATION.  If your authorization people have an issue with my judgment, I’d be more than happy to go a few rounds with your peer-to-peer reviewer about whether a sleep-related medication is medically appropriate.  Again, my consultation fees would apply, but I’m succinct, and I will be happy to provide written documentation of my opinions, complete with literature references, so your reviewers can be educated (and therefore avoid the requirement for more consultations!).

My final words before parting:  I had several conversations with colleagues about this incident before I chose to write this sharply-worded communication.  I got eye-rolls and groans from all of them.  Everyone I interviewed has felt what I’m feeling, and your company in particular has garnered a lousy reputation for giving doctors a hard time.  One colleague said (and I quote, verbatim): “They need to know that their service is the worst ever.  It’s even worse than Medicaid.  In fact, come to think of it, Medicaid is a breeze compared to Express Scripts.”

I think that says it all.

I implore you.  Fix this problem before you burn all of us out.

Sincerely yours,

David E. McCarty, M.D., F.A.A.S.M.
Associate Professor, Division of Sleep Medicine
Department of Neurology
Louisiana State University Health Sciences Center
Shreveport, Louisiana

Attachment
INVOICE for SERVICES RENDERED

To: Express Scripts

From: David E. McCarty, M.D., F.A.A.S.M.

RE: consultation fee

Date of service: 10 January 2014

Time in : 10:15 a.m.

Time out: 11:30 a.m.

Total time: 1.25 hours

Hourly Rate: $350

_________________________

Total: $437.50

Payment due upon receipt.

Please remit payment to:

Dr. David McCarty
University Health Sleep Disorders Center
1501 Kings Highway
Shreveport LA 71130

Thanks for your business!  🙂

————————————————————————————————————————————–

Heather’s Note:

Express Scripts is a pharmacy benefit management organization (PBM): They administrate prescription drug programs for insurance companies, either paying for drug claims, or providing cost-saving measures such as mail-service pharmacies and electronic ordering for physicians. In my own experience with Express Scripts, who just happens to be the PBM for my insurance company, I tried out the mail-service prescriptions for three of my four migraine drugs. It was cheaper and convenient: I could get 90 days at a time instead of 30 (although why my local pharmacy couldn’t give me 90, I was never told). Unfortunately, two of the drugs were different—and for me, inferior—formulations. When my side effects increased (somnolence), I switched back to my local pharmacy. After a few months, the price went up. Although I was never moved to write a letter of complaint (my fix was easy and relatively cheap), I still get the drugs at my local pharmacy. I throw out every letter from Express Scripts imploring me to go back. There are many. When I came across this letter through a friend and former colleague, I readily agreed to post it for the world to enjoy. And hopefully spread.

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61 thoughts on “One physician’s creative response to bureaucratic frustration

    • I feel the same way! Ironically, after a few months of paying more at my local pharmacy (the penalty for not using Express Scripts), a NEW generic came out, and now I’m paying $4 a month because I don’t even need to use the insurance at all. I bet that wouldn’t have happened at Express Scripts.

    • Amazing. I almost cried. Thats a Hell of a Dr. Don’t let him go!!!! Unfortunately I have to suffer with military clinic doc. The one u had for 3 years was lovely and great and understand me. But seperated after having a baby. My current doc? He is a great guy although he may be to kill me. Of the 4 times I’ve seen him 3times he has given me or tried caught last at pharmacy an XR med. I used be 246 pounds had gastric bypass now healthy 110. We talked about this. For 20 minutes. Then gave me concerta. Which I didn’t know was…. Ritalin but XR! Who figured this out? I did!!! He just forgets I guess and writes stud for XR. He made me try the drug in the letter I’m glad it works for this woman but it did not work for me! But still I had to stay on it 2 full weeks. I’m grateful to be able to get it free on base as I know The cost as my doc told me over and over again. But it made angry all the time and so lethargic. I just wanted to be left alone and in bed with my iPad. A woman stepped on my foot in line at the the store and I almost punched her in the face for it. For real. I’m serious. I’m 110 pounds and the most non confrontational person ever except on Provigil!!!underneath I was always like…..edgy and come on let’s go!in short PROVIGIL made me a zombie bitch. Who wanted to fight you. So so NOT my personality. It works for so many my doc called it the “Cadillac of drugs” he was so sure if I just took it long enough…. 2 weeks was enough. I just wasn’t me. So now are finally trying the adderall I asked for a month ago. At “non therapeutic does” every 2 weeks. It’s madding. This did work!!! I’m awake! 20mg
      ( tried to give me XR again) X1 a day. Well awkr for :m3-4 hours. Now we are up to 2x a day so I pick which six hours I really need to awake. And every 2 weeks we talk about how it’s a dangerous drug yada. I do hope he ups it to at least 3 times a day. 4 would be perfect but it has taken 6 weeks to get this far. And you know he keeps trying to kill me with either a med I’m allergic to when I get to pharmacy or the is XR. maybe he is trying get rid of me???

    • Me too! Any doctor who can write a note like that is the one for me. Especially if he signs it with a smiley emoticon (that was really there in the original letter).

  1. This letter was exactly what I needed to see today. After having gone through this exact same awful process with Express Scripts over the past week I have been frustrated to tears. This fellow frustrated physician expressed my exact sentiments much more eloquently than I would ever have been able to. Thank you!!!!!

  2. Hail Hail to Dr. McCarty!! A very well written letter. Maybe someone will sit up and take notice! I hope that if they don’t pay your bill you sue the pants off of them. Thank you for standing up for your patients and yourself. If I ever have a sleep disorder, I will come to see you!

  3. My situation is similar except I need anti rejection medications following a liver transplant. If I don’t get the prescription soon…well guess what happens to me & guess what my family will do. The only real winner will be lawyers – a group we wouldn’t need if companies did what they are supposed to do.

    • I have had the same problem following kidney transplantation. I finally found an insurance plan that allows me to fill the rx at a local pharmacy. It costs a bit more, but the stress in dealing with the mail-order pharmacy was worse. Having been through chemo, plasma pharesis and dialysis I thought I was pretty tough, but dealing with the mail order pharmacy left me in tears on more than one occasion.

    • There should be a provision that allows you to get things filled at your local pharmacy when the mail-order pharmacy doesn’t get you your meds on time. Ask your benefits coordinator how to handle it.

  4. The reason your local pharmacy can’t give you a 90-day supply is that the insurance company WON’T LET THEM. Most drug plans cover only a 30-day max supply through the local pharmacy, though they will allow themselves to dispense a 90-day supply. In this way, they cut out the “middle man” that is your local pharmacy and pharmacist, and keep their costs lower. If they have to pay another pharmacy for your 30 days supply of drugs, they have to pay the pharmacy a reasonable fee for the drugs (to cover the cost of the drugs, and a little extra for the pharmacy to pay overhead and make a little profit); but if they fill the Rx themselves, they only have to pay *their* costs and overhead, and can keep anything left over as profit. So, it saves them money to have you get a 90-day supply of drugs than to pay the local pharmacy 30 days times 3.

    • That makes sense! Thanks. Mail-order was convenient, but I still like the face-to-face encounter with my local pharmacy, the ability to get emergency refills when I on occasion need them, the friendly advice, and all the other unexpected perks that came with my unexpected chronic illness. I LOVE my local pharmacy, and I’m willing to pay more for the experience.

  5. Have had the worst time with Express Scripts!! I would rather pay more money than deal with these idiots!! I go to my local pharmacy. I, myself, have to deal with the “pre-authorization” and my doctors hate it!
    If every doctor charged a consultation fee, maybe they would get their act together.
    Melanie, RN

  6. Very well said! I am super impressed! I have said that it seems strange to me that the company providing the insurance coverage for the medicine is also the one they expect you to use to purchase that medication from! So, they make the rules about where you should buy your medicine and how much they will cover if you don’t buy it from them! Something sounds VERY wrong with this picture! I have been having an issue with Express Scripts and my migraine medicine also. I thought my doctor (a neurologist, who should (and does!) know a thing or two about migraines) had cut back last year on the number of tablets I was “allowed” each month. When I asked him about that, he said that he writes the prescription for more but that frequently the insurance companies will limit the amount. This time I know that he wrote it for 27 tablets a month, but again, I only receive 9 tablets for each 30 days! That is NOT what my physician, who is the one treating me, wrote the prescription for! Who are they to change his order? I say we need more physicians like Dr. McCarty!

  7. While I can certainty appreciate the physicians frustration with the process, and would see why they would want to be reimbursed for their time and effort. The reality of this situation is it would be the patient not the PBM that should be billed. The patient is the actual consumer and by either directly or through their employer sponsored plan electing to give ES their business and as such act as their intermediary in exchange for premiums lower than other providers this is what you get. The other reality is PBMs are the true middle men that lead to inflated prescription cost and wasted time, all under the cloak of reducing cost.

    • Thank you H for posting and to Dr M for writing the excellent letter. Jim, you bring up an excellent point. But additionally, the end-consumers (patients) and providers (doctors) of healthcare are sometimes forced to deal with situations as illustrated in the letter, and the middleman (the insurance companies and presciption medicine benefit payors), instead of being allowed to cloak the cost inflation, should be made accountable for cost efficiency and customer service as is every other business.

    • I, too, loved this physician’s response, but I have to disagree with you, Jim, when you say, “… it would be the patient not the PBM that should be billed [by] … electing to give ES their business ….” Oh, not true at all. I have chosen, through my employer, to hold and pay for top-shelf insurance coverage. Recently, this particular insurer has – without warning, by the way – decided that only the first prescription can be filled by my local pharmacist, but refills have to go through ES. I refused to sign up for ES and, with every prescription, I called the “customer service” number and repeated the reasons that I could not and would not deal with any mail order prescription service. I would also politely tell them that I thought that their default position of refusing to allow me to refill my medications at my local pharmacy was a restriction on fair trade. (I learned that the fair trade restriction does not apply because the insurer actually will allow you to buy at the local pharmacy, but only if you go through this song or dance with them every – single – time.) I NEVER elected to give ES my business, not even through giving agency to my employer or to my insurer, as the use of ES was NEVER part of the plan when I subscribed. I felt hijacked and I had no hesitation in letting my insurer know this. Repeatedly. For whatever reason, my insurer is, finally and thankfully, no longer harassing my pharmacists and me with this practice. Tricia, RN

  8. Express Scrips is so stupid. I tried to set up an account online and it kept kicking me out because my “birthday was wrong.” I think after sixty years I know when my birthday is! AND, yes, I was putting it in the right format MM/DD/2014. When I typed in my husband’s name, they said that wasn’t my husband! OH BOY! Sure wish the State of Georgia would get rid of Express Scripts.

    • Kathleen,
      You said that your online application was continuosly rejected because they claimed you weren’t entering the correct birthday. You then went on to say that you were entering your birthday correctly – mm/dd/2014. If you are in fact 60 years old (as you say), then I believe the year you were born was 1954 and not 2014 as you say you entered. I’m just trying to be helpful.
      -Karah

  9. I just this last week had the same issues with express script. the excessive hold times were unbearable. I finally had to leave the patients house after being on hold the second time for 40 minutes leaving her holding the phone. She was never able to talk to a live agent. Randy, RN

  10. I know of people who have to use the specialty pharmacy of ExpressScripts to get their cancer drug. They are notorius for not getting the drug delivered in time to begin the next round of treatment even when reordered in plenty of time. The drug is supposed to be delivered through overnite service, but often isn’t filled the day it is approved. Unfortunately this is the only way that this drug is handled.
    The mail order pharmacy that I have to use. For this drug is so totally different from ExpressScripts. I have always had prompt service from them. Yes, my drug has to be authorized once a year, but it coincides with the date that I could have switched insurances. My oncologist’s office hasn’t ever complained about the process, but I wonder how much time they spend getting drugs authorized for their multitude of patients. I laud this doctor for taking the time to write this letter and for doing right by his patient.

  11. Pingback: Prior authorization: a daily frustration | Fred Sullivan

  12. For a few recent years our large employer required that we use Express Scripts to fill prescription dugs. It was impossible to find the right phone number and long wait times, and if you failed to refill early enough to receive your next batch, there was an incredible hassle to have a couple pills prescribed at a local pharmacy (that’s all they would give you) at your own expense until the next batch arrived, which required a new prescription request from a physician. If this emergency occurred on the weekend, you are out of luck unless you could convince your doctor to call in on the weekend. These emergency fills were my own problem but I hated dealing with Express Scripts and told our Benefits Providers every single time I spoke with them about anything, and asked the feedback be sent to our employer. Dr. McCarty nailed it when he stated he felt that the run around was deliberate in order to filter out some orders, after awhile I began to suspect the same. Long wait times, hidden phone numbers for customer service, transfers, all of it, took up so much of my time. Although the idea for billing for time is not new, patients who see habitually late doctors’ offices have done this, the act is apropos and applaud the entire effort.

    Recently, our employer has allowed us to return to pharmacies to fill prescriptions. I have never been happier to see my pharmacist.

  13. Dr. D.E. McCarty’s invoice to Expr Scripts probably will not be paid — but that’s great if it is paid. If not we need class action lawsuits of Providers against PBM’s and among other arguments, we must apply: 1.) ERISA abuses & fraud against workers covered by Employer Sponsored Insurance that contracts with such PBM’s; 2.) Involuntary Servitude is engaged as the choice to watch a patient suffer or die is really no choice at all for any red blooded Physician following a professional oath.

  14. There’s always 2 sides to every story.
    1) If your insurance plan uses Express Scripts or any other mail-order pharmacy, it is because YOU decided to enroll in YOUR employers insurance plan. Details of the prescription plan are in writing before you enroll, but more than likely an individual did not read all the details regarding their plan. No one is ever forced into a specific plan. There are hundreds of other plans that an individual can sign up for outside their employers if they do not agree with their employer’s benefit plan. More than likely, individuals sign up for their employer’s plan because it is a cheaper premium. There’s a reason why premiums are different between plans.
    2) The drugs covered under an insurance plan is always pre-determined before an individual signs up for one. Drugs that are covered under a plan are divided into different tiers and some require a pre-authorization determined by the employer and the contracted PBM to reduce cost for the employer. If you don’t agree with the coverage or the process of the coverage, don’t sign up for it.
    3) The number the doctor was originally provided (probably by the patient) was obviously the wrong number, and if he would have dialed the number 866-310-3666 he would have saved at least 25 minutes so how can he bill them for it. For any company that services the entire nation, there a multiple numbers for multiple purposes. If you call the wrong number, you will waste some time. If there was only 1 single number for a company, then you would have to train each employee every process of the company, which could take months/years, and raise the cost to employ an individual with that kind of skill set, thus increasing the cost of service by the company.
    4) Pre-authorizations/Prior authorizations do not have to be done by phone. PBMs have forms that a doctor can fill out and mail or fax in. Once again, this doctor is not very efficient and could have filled out their form or have a member of his administrative staff call to at least initiate the process.

    Do people really believe this doctor deserves $437.50 for a phone call where he initially called the wrong number and then performed more of an administrative task?

    • ES has just wormed themselves into being a provider for more companies than they can obviously handle – and that is garbage. Their phone services sound the same today as they did years ago when I first encountered them. Standing like a dear in headlights as better technologies and ways to interface with customers have improved drastically…but just like the cable companies, or cell companies, when the options are so limited – what can you do as an individual but complain and try to go local (if that’s an option for what you need).

      As for phone numbers, it’s very simple to branch a single number to multiple employees who are cross-trained receptionists who can answer simple questions, and then transfer you to the next tier of specialists. There will still be wait times….but it’s not an automated phone tree, and you squash the risk of holding for the wrong reason.

    • John Doe makes an excellent point about shopping around for insurance companies–something most people (including me) rarely take the time to do. I read every detail provided for me by the “HR Benefits Enrollment Package”–but of course nothing prepared me for dealing with the realities of a PBM. This conversation has. There is far more to a plan than the cheapest premium and lowest co-pays.

      However, I have a lot of sympathy for Dr. McCarty and his frustrations…I’m assuming this wasn’t his first attempt to authorize the drug for his patient (or else the patient’s father wouldn’t have been moved to write a letter). If it were me, I would have called the number provided, too. And how could he delegate the task, when the authorization process clearly had to be performed by a physician? Haven’t we all started a task, thinking it would take but a few minutes….only to find ourselves sucked in by a diabolical call center? The weak give up. The strong persist, at all costs.

      The hero bills for his services.

    • I’m, sorry, “John”, but you are wrong on so many levels here.

      1) ES has a vast multitude of phone numbers and routinely seems to give the wrong ones out (purposely, I suspect) to both patients and physicians. For a single Rx approval I was given one number by the patient (that he was given by ES), a different number on the ES website, a 3rd number on the form I was given to fill out, and finally a 4th number by the initial person I reached when calling the other numbers. There is simply no way it is so technically challenging for there to be a single phone number to call for medication “preauthorizations”. None.

      2) The insurance company agrees to cover the drug and that is their contractual obligation. By throwing up administrative roadblocks they are attempting to skirt this responsibility. It is absurd to require “re-preauthorization” once this is already accomplished; it’s a blatent attempt to circumvent the agreement. As for your advice to “not use it if you don’t like it”, well, yeah, sure– but that is far beside the point of how abusive the practices of ES are, isn’t it?

      3) See 1)

      4) Actually pre-auths often do need to be done by phone because they require a physican’s input. Agreed that sometimes the process can be begun by fax but again, there is the issue that you are put in the position of *waiting for ES to call you back*, which they never, ever do (this from sad experience). So what the doctor did was actually the most efficient option in this case. Also, not all of us have a lot of “administrative staff”, and even when we do, their time is better spent elsewhere.

      I will note that ES does not accept phoned prescriptions, only faxed, which lack the essential element of **confirmation**. Over the phone, a pharmacist reads back and confirms the Rx for safety. ES does not allow this, and sends no confirmation that they have received the info on a fax.

      Do people really believe that doctors deserve to be paid for their time? Hell yes. Why don’t you believe that, is a better question.

    • The fact is that regardless of what one’s insurance company says, Express Scripts has a horrendous reputation. My doctor’s office has a sign saying that employees who wish to use a mail order pharmacy will be given a hard copy of their prescriptions, and will need to deal with the mail-order company themselves.

      Your comments about insurance are unrealistic. My insurer has discontinued our plan every year for the past six years. Two months before renewal time, the company makes an appointment and presents our management with the new options. It usually begins with, “We are no longer offering that plan, but here are some plans you might consider that are similar.” Similar having a strange definition meaning of, “you pay about the same amount of money but get much less coverage” or “you don’t have quite the same coverage, but you can get close if you’re willing to pay a whole lot more.” We can (and have) shopped around, but everyone wants to see what your current policy is and then pitch comparable plans. Six years ago for a $700 per month premium we had a $10/20/30 prescription benefit, $20 copay for office visits, $75 copay for ER visits, $200 annual deductible, $1500 out of pocket max, and could get $200 toward lenses and $150 toward new glasses annually (or get contacts instead, if preferred). That has changed every year to where we now pay $1765 per month, have a $10/35/70 prescription benefit, $35 copay on office visits, $250 copay for ER visits, $1500 deductible, $5000 out of pocket max, contact lenses are not covered, and glasses are only covered every-other-year at $100 toward lenses and $100 toward frames. Dental coverage has stayed about the same.

      I couldn’t shop around and go get a private policy because two family members have pre-existing conditions and are considered uninsurable. Now with PPACA I have looked at the exchanges and discovered that for about the same amount of money I could get a plan with no vision, no dental, an even higher office-visit copay, and a prescription plan that does not cover tier 3 drugs. It’s no contest.

    • Please note my response to Jim’s post on Jan 18th. My employer is a state government and we are offered a myriad of insurance plans. The one I chose, which had one of the highest premiums, DID NOT include the mandatory use of a mail order pharmacy when I signed up. There was a choice – I could use ES or I could use a pharmacy, but I would pay a higher price. Suddenly and without warning, my insurer (or possibly, employer, but colleagues who carried other insurances were not having this problem) decided that they were going mandate the use of ES – unless I called them every single time I needed a refill. They would not just put a blanket note in my file saying that I opted out of ES, I had to opt out with every single new prescription. So, I did. And, I told them (politely, of course) exactly what I thought of their no-notification-arm-twisting tactics. Perhaps they got tired of hearing my voice and reading my letters, but they no longer harrass me or my pharmacist. I also wonder how you can say that it is the doctor’s fault for calling the wrong number at ES when so many other ES participants have had the exact same problem of being unable to identify the proper number to call. “Oh, it’s Thursday and your last name begins with G and you were born in Dec. Don’t you know that you Dec. G’s are supposed to call the 3667 numer on Thursdays? I know, last month it was March R’s on Thursdays and Dec G’s on Mon, but it changed. And, it will change again next month.” Obviously, ES could do a much better job of customer service – if it was a company priority.

    • It certainly seems no more absurd than charging employers a significantly higher rate for prescription drugs than they reimburse the pharmacies-where the PHARMACISTS fill, check, consult and (shockingly) interact with patients rather than simply pocketing the cash.

  15. Fun letter, horrifying reality — We should all be so fortunate to be under the care of a tenacious and creative doctor. Hopefully and until the bureaucratic walls come down, the good doctor’s letter will encourage a grass roots effort including other doctors and colleagues to follow suit. As a patient diagnosed with idiopathic hyperosmnia, I am filled with gratitude for those who advocate on our behalf. Living with hypersomnia is dreadfully hard and action like this adds both validity and hope to our plight as we try to live between the zzz’s. Thank you! For those interested in learning more about living with hyerpsomnia, there is a website offering information and support for patients and supporters of hypersomnia, http://www.livingwithhypersomnia.com

    • Horrible… We surely wouldn’t need to face situations like this on the top of what we already need to go through. Seriously I wish we could thank this Dr. And make him aware we deeply appreciate his care and the fight he’s fighting for us since we have no strength to fight it ourselves. Beth or Michelle, do you know him or who he is? Is there a way to show him our gratitude? He truly needs our encouragements (at least)! (If we want him to persevere…..It’s rare enough to see someone as determined as he is!)

  16. Pingback: Bureaucratic Frustration | David F. Clark

  17. Dear Dr. McCarthy,
    I would like to commend you on taking the time to express your frustration. I am also a specialist (Allergy & Immunology) and go through your frustrations weekly. I guess like others in the same position never spent the time to put our frustrations in words. I hope that you will continue to let these companies know about what the prior authorization process has done to physicians like ourselves. I applaud you sir.

  18. Well…this explains why *I* could not get my Provigil rx filled for IH through Express Scripts a year ago. Worth noting is that prior to Express Scripts being bought out/merged/whatever flavor of the day fun title you want to call it with Medco, that I had 0 problems filling my prescriptions. Once the merger happened, they suddenly couldn’t fill my RX because they didn’t have a shipping address for me…which is funny since they didn’t notify me via e-mail or phone. Nope, they sent a letter to my house and another to my work! That’s right letters….to physical addresses. After 2 rounds of that and them “correcting” it, my letters now said I didn’t have pre-authorization. As long as my IH meds have been prescribed from a sleep disorders center (which they always have), I’ve never had problems. I had a question regarding that at one time with a previous employer because they had BCBS, so I had to deal with Medco then…which was a hot mess. So I’m reasonably sure that’s the issue with Express Scrips now, because Medco was so incredibly incompetent. I had several months of reserve of Provigil when I switched employers, so it should’ve been find, but they couldn’t fill it in 3 months, so I just ended up going to my local pharmacy and paying the normal copay instead of saving 1 copay by doing 90 days through Medco. Medco kept calling me and saying they needed to confirm a drug interaction (which wasn’t a problem for me). They told me it had to go through 6…yes 6 pharmacists, so that’s why I was getting a call from each one! Unbelievable! Then, they couldn’t figure out how to get it from the pharmacists to the shipping dept. I gave up. So much incompetency. I’d rather pay regular copays than saving on 1 month than to deal with Medco/Express Scripts ever again. This letter was spot on. Thank you for advocating for your patient too. The stimulants are in no way a miracle cure, but they change someone with IH from being non-functioning to functioning. You don’t have the energy to fight this kind of thing without them. Thank you!

    • I had Express scripts years ago and had nothing but problems. Then my employer switched to Medco and the problems went away only to return when express scripts merged with Medco. Now I have to go on a different asthma drug because ES will no longer cover it.

  19. After a month of answering the same question over and over…not kidding. I decided I would call this company one more time. If I didn’t get the desired results I was going to call the president of this ExpressScripts/Accredo. Their delay tactics were borderline negligence in my book. A painfully familiar conversation began. I assured the person on the phone that though this was a new conversation for her; it was a month old one for me. I asked if she could understand my frustration. I also asked if she could initiate a 3 way call with me, them and the patient. They claimed they either couldn’t get in touch with the patient or the patient didn’t know why they were calling. She couldn’t. I asked if I could hold while she contact the patient. I could. She did. Patient finally got her medication. I asked to speak with this employee’s direct supervisor( not a new request). Employee paused. I assured her I merely wanted to give her a compliment. I did. In the process of doing so, however, I let the supervisor know of the horror story my patient went through while awaiting her medication.

    More doctors need to get involved the way this one did and charge for their time. The doctor, for whom I work, would have made a small fortune.

  20. Thank you doctor for all your work!! This shows how much you care for your patients. It also shows the frustration that many doctors feel with all this managed care red tape. Not only do I feel your are correct for sending a bill for your time in which you could have serviced at least 5 other patients. You went to school in which you paid massive amounts of money to do. This is so some other person can make a choice as to if a patient can or cannot have their medication. How do we know what that persons credentials are. These questions are always the same and I agree that once an approval is given for a condition that will unlikely change there is no need to repeat the process. Further more if these companies want so much control (this include the drug companies) they should help pay for malpractice insurance. It is their requirements that can lead to multiple complications for patients who cannot obtain the medication they need for their health.

  21. I did the same thing yesterday. Stayed back after clinic and tried to get a prior auth but this time it was medicaid. They kept stalling, and i could swear they were intentionally trying to make it painful. At one point I even asked the representative if she needs the patients favorite color too. I had to spell out simple words so I know the person on the other end was not medically savvy.

    Patients get mad at us and insurance companies try to play games. They keep cutting reimbursements and are pushing physicians against the wall. God forbid the brightest in the nation find themselves against the wall too long, because you don’t want to see how we’ll fix the problem

  22. In response to John Doe: I agree that employers provide employees with the terms of coverage for review prior to signing up for company sponsored “health” benefits. But rarely do they provide you with full information on the PBM benefits. Usually a link to the PBM, if accessing these reviews online, is provided but good luck with that. But that does not change the fact that the prescriptions “covered” by the PBM, or requiring a Prior Authorization (PA), can change anytime the PBM has a therapeutic review. Just yesterday I was denied my medication for EDS (excessive daytime sleepiness) & PLM (periodic limb movement, a condition that disrupts my sleep) because a PA was required. As it has been for the last two years and is up for a PA renewal (never needed a PA prior to two years ago). That’s fine and grand, but I know, as the good Dr. did, it’s the same two questions again this year. Being I’ve suffered from these disorders for many years and have been efficaciously maintained on what the professionals would describe as a low dose, I doubt I’m abusing or seeking these medications because I’m addicted or selling them on he streets, and I’m pretty damn sure this condition isn’t going to miraculously go away. I agree with the Dr., save us all the hassle and approve these for extended periods. Oh and should I mention that I am in sales and spend an inordinate amount of time behind the wheel of a car on the interstate highway. Without this medicine I’m at great risk of dozing off behind the wheel. Guess I’ll keep my fingers crossed every morning when I head out to work until my PA can get Re-Authorized. To note again on choosing to sign up for employer benefits, it would have been beneficial to know prior to “open enrollment” (October) that two of my previously covered medications are now not going to be covered in the new plan year. Yes, I received that letter after I re-enrolled in the plan. I’m in a healthcare related industry and I understand the nuances and ins-and-outs of prescribing, PBMs, PAs, cost containment, coverage, co-pays, carve-outs, 3, 4, & 5 tier pharmacy benefits, CPT codes, ICD9/10 codes, hospital re-admission fees, EMR and fees for non-compliance, CMS and the list goes on and on. What I don’t understand is how it can be so hard to get anything done in a timely, orderly and easy manner. I remember the days of the old indemnity plan: I went to the doctor, I paid the bill, I submitted my receipt for reimbursement, and for my prescriptions, and the insurance company sent me a check. Wha-La! Done! Quit killing us with paperwork and road blocks to getting the medications our doctors know are medically necessary to treat the conditions they spent many years in advanced eduction to learn to diagnosis and treat appropriately.

    • Right on, Frustrated. I have already posted two replies about my insurer suddenly mandating the use of ES, a battle which I fought and, for now at least, have apparently won. What I didn’t mention was that this same insurer decided that I did not NEED the 30 tablets of a medication as prescribed by my physician per month; I was going to “be allowed” only 10 tablets per month. What? I was told that the insurer’s physician consults determined that it is “in [my] best interest” to limit this Rx to only 10 days a month, not 30. Oh, really? And, when did this physician consult examine me? (It was at this point that I might have mentioned to the agent that as a legal nurse consultant, I am intimately familiar with the laws that regulate the practice of medicine in this state, and I was very interested in what I was hearing.) Ultimately, I took the 10 tabs “allowed by” the insurer and paid cash for the remaining 20 tabs. After doing this for a couple of months, I realized that, because this particular drug did not have a generic form, meaning that a higher co-pay attached, I could purchase the entire 30 tablets per month out-of-pocket for only an additional $10, and with a LOT less frustration! After a while, a generic form of the med came out and the “physician consultants” no longer cared how many tabs I took. Tricia, RN

  23. I do applaud this physician for taking a stand certainly. I do need to ask something however; would you feel equally as justified if a patient billed you for the time they spent in your waiting room after their scheduled appointment time?
    For as frustrating as this process was for this physician, it is no more frustrating than to schedule a one o’clock appointment with your physician, only to be left sitting until two or two thirty (or later) just to get in to an exam room, where you sit another half hour before you actually get face time.
    Maybe patients need to start billing physicians for this down time as well. They probably wouldn’t be a fan of the practice.

    • In our clinic we have a show-rate of about 60%. So its not easy to schedule patients and then sit there for empty blocks because they decided not to show. Some clinics charge a no-show fee of $30 dollars from the patients and their show-rate is over 95%. Maybe thats better to do

      On the other hand, patient care is not like changing oil in a car. Every patient is different and even to us, what seems like a quick visit suddenly becomes an hour long visit because of a complication or because of something they mention that sounds like trouble. Even getting information from patients is difficult at times and you have to keep going at it until you can get enough information.

      Basically my point is that we cannot work on a fixed patient schedule unless we block out half an hour for each patient and assume that everyone will show up. Your govt and insurance company gives us enough money that we need to see approx 6-8 patients (depending on the field) to break even.

      We can use different strategies to minimize the wait but you have to realize that the quality of healthcare is difficult to maintain if they keep cutting reimbursements and the volume is needed just to keep an office open.

  24. Getting methotrexate for rheumatoid arthritis has gotten horrible from almost all of these types of companies. It is getting more and more expensive even though it is old and in common/standard use, and patients get told by the pharmacy plan employees that it is a cancer drug, and asked why would they be taking it for RA…

  25. The issue here is the length of time for this doctor to complete a prior-authorization process and not whether a drug should be covered or not covered by a patient’s insurance plan (a patient can purchase a better prescription plan or request coverage information regarding their medications from the benefit provider before they sign up to solve that issue) .

    For those that think this doctor should be commended and that ExpressScripts should pay his consultation fee, then shame on you!

    There’s this resource that I bet everyone uses called the world wide web, aka the internet. I bet Dr. Persaud, like Dr. McCarty, ever tried looking up the information online before making that call they so awfully dredge. They just trust the patient’s word that they should know better on how to solve the problem when it comes to their insurance.

    What took the doctor at least 25 minutes to get the right phone number (because his patient gave him the wrong number) and complete the Prior-Authorization process, I would have finished all of it in less than 5 minutes.

    If you google “Express Scripts”, click on the first available link, http://www.express-scripts.com/, click “Express Scripts corporate site” for Clients, Advisors, Pharmacists, PHYSICIAN, and Investors like it says on the website, then click the next link “PHYSICIANS START HERE”, the doctor would have found at least the correct phone number to call. So it took the doctor 25 minutes to find a number I found within 4 clicks of my mouse. From there, the doctor could have clicked the next link to download and fax the Prior-authorization form for his patient and be done with the process.

    The doctor admits he knew the patient required a prior authorization every year, yet, he doesn’t know what number to call so he must not be a quick learner. Also, he could have easily set a reminder in his calender 2 to 3 weeks before the expiration date of the prior authorization to fill out one of these forms to fax to Express Scripts before the patient ran out of their medication. Like many doctors in this country, they do not act proactively, but more so react to situations. If doctors would bookmark each mailorder’s website and set reminders in their calenders to write new prescriptions or fill out Prior-authorization forms before a patient is to run out of their medications, it would save everyone some stress and hassle.

    It is ridiculous that this doctor believes this was worth $437.50 for this process and is one of the many reasons why the health industry is only going downhill.

    • ES does not give a confirmation of a faxed prescription or pre-auth. Of course, you can keep your electronic or paper copy, but you still have no way of knowing whether the pre-authorization was received, channeled to the correct person, or will be accepted. The only way this will be learned is when the patient needs the prescription filled and ES denies the Rx saying that a preauthorization is needed. The doctor will still have to call and tell them. “I did one, the copy is right here.” Es will say, “We don’t have it.” “Here, I’ll re-fax it.” “We didn’t get it.” Honestly, that’s how it goes and the process starts all over again. Really. I have frequently turned to a website for phone contact info only to find the info is incorrect or out of date. You are not out there in the real world of medicine and have no idea what it entails. Imagine this scenario. You are a procative physician and you set up pre-auths for as many patients as you can to occur 60 days before the Rx is due. Now, you find out that a percentage of your patients have moved away/ changed doctors/ changed insurance plans/ or simply doesn’t show for a yearly visit and are lost to follow up. Now, you have re-ordered and pre-authoized a medication for a patient that you did not examine and, quiote possibly, haven’t even laid eyes on for a year. Knock. Knock. Hello, I’m from your state medical board and I need to discuss these 300 fraudulent prescriptions you wrote. Honest, they aren’t fraudulent – I was being proactive!!
      Your ignorance of medicine and its tangled bureaucratic web are showing, Powered. TCG

  26. Pingback: On Encouragement | Fine Feathers

  27. Express scripts is absolutely horrible. I have been fighting with them for almost a year now to get my daughter a 3 mo. Depo Lupron shot she desperately needs to control the pain of her severe endometriosis. She has already had surgery once to remove scar tissue are age 17! Our physicians office has spent hours on the phone with them argueing which insurance should be primary when they know and have been told that tricare is always primary. We are still waiting to receive a delivery date for her medication which btw she has received 3x before wo a problem!!! If my daughter needs surgery again to repair scar tissue damage from having to wait so long for her medication I plan to sue thus company for pain and suffering! As I’ve watched my daughter in excruciating pain for almost a year! I myself have run into problems with this pre authorization bull. These Inc companies are just plain ignorant. If the medication wasn’t needed, the doctor wouldn’t have written it!!!!! I applaud this doctor for writing this letter, & hope more like him will step up & start taking a stand!

  28. I’m not sure which websites Patricia Garison has visited, but the Express Script website did list the Prior Authorization number the doctor eventually had to call (I checked). It is hard to imagine that a Fortune 500 company would put the wrong information on their website, but if they do, someone should provide some feedback.

    Regarding her comment about being proactive, I guess she disagrees with the doctor in that prior authorizations should NOT be approved for an extended period of time, similar to prescriptions expiration dates. If prescriptions did not expire after a year (less for controlled substances), then patients would never come back to see their doctor for their conditions. This is probably another reason why the insurances require the prior authorizations on a yearly basis, as well as insurance plan’s formularies changing every year.

    • I read through your blog–you are an inspiration to anyone dealing with Express Scripts or any other such company! Your post “http://valeriamsouza.wordpress.com/2014/01/15/chronic-illness-and-the-question-of-access-a-primer-a-manifesto-in-one-post/” was particularly insightful and full of helpful tips. Bravo for all your hard work–and for taking the time to blog about it.

  29. If PHYSICIANS would be more proactive when it comes to prescribing drugs that require prior authorization….it would save patients, the insurance companies, and the pharmacy so much time and hassle! As a pharmacist I would say that around 25% of all medications prescribed require a prior authorization. Almost every insurance plans formulary is available for view online. The prior authorization phone number is available online (each plan only has one number….not multiple). The prior authorization phone number is also on the back of every patient’s insurance card….which every doctor’s office makes a copy of. Also, a physician can call any retail pharmacy if they can’t find the number online or on the back of the patient’s insurance card and we can give the number to the physician. In an ideal world it should work this way: the office manager of the doctor’s office sets up the websites of all major insurance carrier’s in the area and their formularies under “favorites” so it is easy for the doctors to access from their computers. This way with a click of the mouse if they prescribe a new prescription they can check right then and there if it is covered or if it is going to need a prior authorization BEFORE they prescribe it. They also should have a calendar program that alerts them when prior authorizations are set to expire. The office manager should have printouts for each of the major insurance companies prior authorization forms. If the physician knows a drug is going to require a prior authorization the physician will fax off the paperwork before the patient even leaves his/her office. Or….he may see a drug on the patient’s formulary that he could prescribe that will work just as well in his opinion that will not require a prior authorization (nasacort vs. nasonex…etc). This way the patient knows it may take a couple of days for the paperwork to be processed….or the doctor is able to prescribe something that is on the formulary and the prior authorization process isn’t even needed.

    Instead this is what happens 95% of the time: we receive a prescription from the doctor’s office…..we send it thru to the insurance company…..they reject the claim and say it needs a prior authorization….it costs 900 dollars so the patient can’t afford it if the insurance will not pay for it….the patient is totally surprised to hear this b/c the doctor never checked the formulary before prescribing the medication (reactive vs. proactive) and so the patient curses us out and thinks we are to blame for them not being able to pick up their medication….we fax the doctor’s office or call if they are an electronic prescriber (b/c we can’t fax electronic precsribers)….we are always put on hold or transferred to voice mail…..if we do talk to someone after waiting on hold for 15 minutes we are told that we must fax them the information and when we ask “why can’t you just please write it down? it’s just a paper saying John Doe needs a pa on his nasonex please call 1-800-999-8888. Can’t you write that down? And we are told…no we must have that faxed.”…..so we type out a manual fax saying what we just were on hold for 15 minutes to say to the person on the phone. Everyday we try to rebill the claim and it doesn’t go thru….so we call the insurance company and are on hold for 30 minutes and have to talk to automated machines for the 50th time that day and finally get to a person and they say “we did receive a prior authorization for the medication and it is approved….but it needs another authorization for the quantity….the doctor wrote it for twice a day and we only approve it for once a day.” At which time we have to do all of the things in the beginning of the paragraph again. The kicker is….when you are filling 800 prescriptions a day and 25% of the prescriptions you are filling need a prior authorization….you do the math as to how much time we waste daily on hold on the phone waiting to talk to insurance companies, doctors, and patients about prior authorizations. I agree with the doctor that the entire process is ridiculous and prior authorizations should last longer and it is most certainly the insurance companies way of putting up road blocks in the hopes that you will give up and they will get away with not paying for the expensive medication (and this approach works b/c we have many doctors who simply will not call for pa’s). But……there are things doctor’s can do also to make this process easier for everyone. If we are going to get paid for time wasted on the phone with insurance companies that could have been spent helping patients instead…..I need to get my invoice ready b/c I will have a house on the beach in bermuda paid for in full.

  30. Pingback: Third Wheels Part 2 | The Doctor is In...sane

  31. Pingback: 5 Key Challenges for a Doctor Serving Humanity - Prospective Doctor

  32. This company is a nightmare to deal with. They are putting people’s health in jeopardy. They make health “care” a joke as they are all about profits.

  33. Pingback: 5 Key Challenges for a Doctor Serving Humanity | Healthy Practice

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