The new year, new horizons, new challenges...and a new year for pateints' copayments, deductibles, and calendar year activity. This is an especially painful time. Patients don't know what their plans cover. They don't know what they're paying for. I blame the agents and the plans themselves, for perhaps providing information, but not providing understanding. Patients also have the ostrich-head-in-the-sand attitude, they don't want to know anything until they get a bill, then they start screaming. Literally. I am the face and the bricks-and-mortar location where they can walk in and scream. One lady looked like she was going to burst a blood vessel in my waiting room she was THAT agitated. Um, your plan didn't pay anything because you have to spend $5000 first before it kicks in. There are 800-numbers on the backs of their cards but the patients do not call and verify anything. Their agents sit back and demand payment for the policy and they can't (won't) answer any questions about the products they sell. They refer them to the 800 numbers on the back of the insurance card!
I am SO BEYOND FED UP. I am not an insurance agent, adjuster, nor processor. I do not magically know what your policy will and won't cover. I resent SO MUCH being in the middle of this tug of war and being attacked for doing my job. We have now started charging a nominal fee for doing "prior authorizations".
What is a prior authorization? Well, firstly it is a complete misnomer. It sounds like it would be something you do prior to seeing the patient to authorize some service. Nope. It is an ex post facto thing that I, the "prescriber" must do when the pharmacy calls me and states that Mr. Smith's drug is not being paid for by his insurance plan. I then need to speak to someone at Mr. Smiths' pharmacy benefit office, someone normally with a minimum of a high school education, who then screens my call and a staff pharmacist will then call me back. A day or two later, the pharmacist FROM THE INSURANCE COMPANY will interview me as to why Mr. Smith needs this drug. My doctors' degree, NPI, DEA, state license, etc are not sufficient to ensure that I know what I'm doing. This all a delay tactic to NOT pay for Mr. Smith's drug. I then have to fax the records and letters to get the insurance company to pay for the drug. After all this, they usually deny it and the patient must foot the bill. Meanwhile I have spent hours with this back-and-forth and my staff has spent untold time on this issue for which we are not being paid.
A bank charges $40 for a bounced check. Medical offices need to charge for employee and staff time, faxes and the toner, paper, etc. in dealing with essentially a negotiation to try to get a drug paid for a patient. This has gone beyond the pale. I am being continually harassed by all the above involved parties--patients, pharmacies (why do they care where the money comes from, whether it's the insurance plan or the patient? aaah vested interests mesh tightly....), and insurance plans to do this thing where, as far as I am concerned, my responsibility has been vacated. I interviewed, examined, and diagnosed the patient. I discussed treatment options and recommended a plan for the patient's disease. This continual snowball of responsibility has not been curtailed by the physicians' representatives/lobbies, the AMA has done the most piss-poor job on the planet of voicing the concerns and issues of the physicians. All they care about is selling the new ICD-10 coding book.
