Prior Authorizations for Medications

For the last 15 or 20 years, insurance companies have required prior authorizations before they would pay for certain, expensive medications. In the past couple of years the trend for the “apple” plans, (those low-cost commercial plans that represent Medicaid), has been to deny virtually every medications that we prescribe.  This includes old, cheaper medications such as amitriptyline or sumatriptan. As a tertiary headache treatment center, we rarely even prescribe these simple medications because the patient has already tried those before coming to us.

The mission of the insurance company is of course to make money and by denying care is the way they make the most money. Part of this strategy is to require the provider’s offices to complete (for free) prior authorization forms before they will pay for a medications. If the medication is not covered, these insurances will tell the patient that it is the practice’s fault for not filling out the prior authorization. Then the patient feels that they must direct their frustration at us if the medication is denied.

The truth is, the prior authorization requires us to pull up and read every chart note we have made since the day we met the patient. Then we have to document the diagnoses, and every treatment that has been tried and the out-come of that treatment. Then we have to fax this paper work to the insurance company. The insurance often denies the medication again and requires a phone conversation. Then (usually Kaaren) has to call and sit on hold for 10-20 minute to talk with someone a the insurance company. This process takes an average of 25-40 minutes per prior authorization.

Now imagine that you see 15 headache patients in a day and write 50 prescriptions. Now, the Apple plan denies 20 of those prescriptions.  That means that rather than taking care of patients who are desperate to get in, we would have to spend 8-10 hours per day just doing prior authorizations and nothing else.

This situation has become unsustainable. We cannot both take care of patients in the office and work on prior authorizations all day.  It is for this reason that we will not see any new apple plan patients.

For those existing patients they must remember that we care deeply about them as we do all headache sufferers. We deal with their insurances out of a simply courtesy to them.  If we choose the very best treatment for our patient  and then their insurance (who has no basic knowledge or understanding in how to treat headache disorders) denies that treatment, they should direct all their frustrations at the people responsible, their insurance plan not us. If enough patients express outrage over this behavior by insurers, the insurers will eventually have to stop.