Cost Savings Options

 For years, as a courtesy to her patients, Dr. Kinney sent appeals and requests on behalf of patients in an attempt to secure the medications that would be most beneficial.  In 2021, Dr. Kinney spent an average of 13 hours/week fighting for that coverage.  So that she may continue to spend all of her time on direct patient care, as of January 1, 2022, Dr. Kinney  no longer completes prior authorizations or formulary exemptions for drug coverage.   

There are steps that you, as the insured, can take on your own behalf.  Most insurance companies (at least reasonable ones) allow patients to submit an appeal for drug coverage themselves.  Contact your insurance company or HR person for details.  If you have insurance, your customer service representative (the number is found on the back of your insurance card) should be able to give you some direction on the process.  Below are some simple steps you can take on your own behalf.

Talk to the Decision-Making Person 

While it’s your health insurance company that requires pre-authorization, it’s not necessarily your health insurance company that makes the decision about whether your prior authorization request is approved or denied.  Your health plan may contract with a radiologic imaging benefits management company to process its prior authorization requests for things like magnetic resonance imaging (MRI) and computed tomography (CT) scans.  Your plan may contract with a pharmacy benefits management company to process prior authorization requests for certain prescription drugs or specialty drugs.  They make more money by denying your coverage.  :(

If you need to speak with a human in an effort to get your prior authorization request approved, the human most likely to help you is the clinical reviewer at the benefits management company.  If you’re not sure which benefits management company is handling your prior authorization request, your health plan will point you in the right direction, but don’t count on your health plan personnel to be able to make the decision about approving or denying your request. Save your breath until you speak to the person who actually makes the decision.  

Read the Clinical Guidelines First 

In some cases, you can see the clinical guidelines the reviewers base their decisions on. This is kind of like seeing the answers to a quiz before taking the quiz, only it's not cheating.  If you cannot find the guidelines online, ask your health plan or the benefits management company you’re dealing with.  If its guidelines are online, they have a fiduciary responsibility to share them with you. You're much more likely to get a speedy approval if you give the reviewer exactly the information they need to make sure you meet the guidelines for the service you're requesting.  

Include clinical information that shows the reviewer you’ve met the guidelines for the test, service, or drug you’re requesting. Don't assume the reviewer knows anything about your health other than what you are submitting.  If you haven't met the guidelines, submit information explaining why not.  If the guidelines say you are supposed to try and fail drug A, B,C,D, E before being approved for drug F and you didn't even try drug A, then you are wasting your time unless you can explain why you can't take A, B, C, D, and E drugs . If you have tried all of the drugs or can't take one of the drugs, make sure that's clearly explained in your prior authorization request.   

Submit Thorough and Accurate Info 

When you submit a prior authorization request, make sure the information you submit is accurate and thorough. Prior authorization requests can be denied or delayed because of seemingly mundane mistakes.