Patients and Physicians Speak Out

It’s a burnout to nursing staff to submit and follow up on medication for prior authorizations. As a nurse, my time should not be used for phone calls to insurance for follow-ups or appeals.

My daughter who is disabled and on Social Security Disability has been on methylphenidate ER for 20 years. She is on Medicare and has a Humana Part D prescription plan. Her medication must be prior authorized each year.

I had a patient in her late forties who had been a smoker since her early teens. She came in with hemoptysis and shortness of breath. A chest x-ray revealed a single 2 cm nodule in her left upper lung field. I wanted to get a CT of the chest to better characterize this as it was most likely lung cancer. The response from the insurance company was she could not have a CT scan until she had first undergone six weeks of physical therapy. Yes, you read that right. Physical therapy. I told the idiot on the other end of the phone that if 6 weeks of physical therapy could cure lung cancer, we would have a miracle on our hands. It still took three more phone calls and faxing over office notes before I could get the CT scan approved. It took almost 2 weeks.

I went almost two weeks without long-acting insulin and two days without even short-acting insulin waiting for prior authorizations. This landed me in the ER 3 times and sent me into a pancreatitis flare. And wasted about 3 hours of my doctor’s time to get insulin. This was not new either; I have been diabetic since I was a kid, so about 25 years. They also made me switch what kind I use, and that caused my sugar to be out of control for weeks, even after I finally got the insulin, while I determined my correct bolus dose of the new insulin.

It is not uncommon for patients to change pharmacy benefit managers when changing health plans or for health plans to change their pharmacy benefit manager.  Physicians and patients get caught in the crossfire of endless forms and calls while waiting for meds, which they have successfully taken for years, are now questioned.  It is very difficult to reconstruct a person's previous med history when we have changed to a new EMR and then find it hard to justify to the PBM why the person ended up on the regimen that is working for them.  It is a waste of time and potentially dangerous.  These requests involve FDA-approved drugs and often generic medications.