Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Friday, September 30, 2016

PA Victory?

I know everyone has problems with prior authorizations. The Byzantine bureaucracy and obscure explanations for denials are maddening.

I'm suddenly reminded of the DMV scene in Zootopia, except I think insurance companies do it on purpose.

Today I had a minor and unexpected victory, and I think I might know why it worked, so I thought I'd share it.

Unfortunately, I have to mask any clinical information, so you'll have to take my word on a number of points. Some things may sound peculiar or not-thought-out, but like most cross-sectional views of a patient's medication regimen, if you knew the full history, it would make sense.

Here's what happened. I needed to get a PA for a new medication, M. The patient had had trials of multiple cheaper covered medications, and had either failed them, or had been unable to tolerate them. The insurance company's criteria seemed to be having failed a 4 week trial of, or been unable to tolerate, two medications.

A number of months ago, I had tried to get a PA for a new med for this patient, and the application was rejected, despite the fact that the criteria were obviously met. I didn't have the energy to pursue it then, and there were one or two more covered meds left to try.

The difference now seems to be that I've since had a Genesight test done on this patient. As I've described in the past, I have my doubts about the whole genetic testing business, but I used the test results as documentation to support my rationale. M was in the "Green Column", and the other meds in that column had already been tried.

It worked! Who knew? I'm only guessing that that's the reason, but I can't think of any other difference. Same patient, same insurance company.

It wasn't a pure victory, though. This medication has a starter pack that's used to titrate gently. THAT wasn't approved. And using a single dose form, starting lower, and then increasing the number of pills per day, well, that wasn't covered, either, because it involved too many pills. What I needed to do was skip the recommended titration, and go straight to the next dose up. Not dangerous, but possibly hard to tolerate.

To me, it feels like a punishment for asking the insurance company to cover the medication.

I guess with insurance companies, you take what you can get.