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.

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.

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.

Prior authorizations take up significant staff resources. We have a full-time nurse and per diem nurse coming in every day spend all day doing prior authorizations instead of helping care for patients or addressing patient concerns. Limiting physician choices in management prevents doctors from providing individualized care to patients. In the majority of cases, prior authorizations delay treatment, which in psychiatry can have dangerous consequences.

I retired a year ago after 38 years in the same office. One of the biggest reasons why I just couldn't do it any longer was prescription prior authorizations. I would sometimes work for 3 months to get an approval only to find out that the patient could not afford the $900 co-pay. (Yes, one patient's copay for a specialty injectable was $900!) … It made me so angry!”