The Battle with Insurance Companies to Obtain Prescriptions

If you are a news junkie, then you know that a tick-tock is a story that relies heavily on chronology, counting down the events of the day, in order, as inexorably as the ticking clock. These types of timeline stories have become very popular in the fast-paced world of modern politics, in which readers eat up the blow-by-blow accounts of the latest scandal.

On occasion, I have been known to keep a tick-tock of my own, largely to figure out why it seems to take me so much time to accomplish so little. On one particular day, my tick-tock would have looked like this:

8:00 a.m.: Called toll-free number to initiate a peer-to-peer review;

10:37 a.m.: Paged to a number with a large phone tree. I could not figure out which option to select to speak to someone;

12:30 p.m.: Called same number again and spoke to Kelly, the pharmacy claims coordinator, who informed me that the drug would be approved if I sent in a note indicating that the patient had received clinical benefit from the drug in the past;

2:05 p.m.: Called the same number. This time, spoke to Jennifer. I reviewed the language of my documentation with her, which stated that the patient had responded to treatment and that continued therapy was appropriate. She agreed that this documentation was adequate.

3:30 p.m.: My office received a call from Carrie, a nurse, who informed me that she needed additional documentation to initiate the appeal. I called back three times to discuss, but reached voicemail all three times;

4:25 p.m.: Spoke to Carrie. She recommended that I list all of the medications the patient had failed in the past, even though the drug had been previously approved. She noted that she was just one of three people who would be reviewing the appeal, and she could not predict what they might be looking for.

I will not bore you with the rest of the chronology, because you may not know the lyrics, but you certainly know the tune. The peer-to-peer review is an interesting concept; it implies that your insurance company is ready to serve as the guardian of sensible prescribing practices, defending the patient from the wanton prescribing practices of the rheumatologist. I have not yet met the Evil Rheumatologist who lives for the sadistic pleasure of starting patients on nonsensical drug regimens, but perhaps he or she lurks among us. For most of us, however, the risks associated with these medications are enough to keep our prescribing practices in check.

Physicians Respond

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