The Rheumatologist
COVID-19 News
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
      • Gout Resource Center
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Resource Centers
    • Ankylosing Spondylitis Resource Center
    • Gout Resource Center
    • Rheumatoid Arthritis Resource Center
    • Systemic Lupus Erythematosus Resource Center
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
    • Electronic Health Records
    • Apps
    • Information Technology
    • From the College
    • Multimedia
      • Audio
      • Video
  • Resources
    • Issue Archives
    • ACR Convergence
      • Systemic Lupus Erythematosus Resource Center
      • Rheumatoid Arthritis Resource Center
      • Gout Resource Center
      • Abstracts
      • Meeting Reports
      • ACR Convergence Home
    • American College of Rheumatology
    • ACR ExamRheum
    • Research Reviews
    • ACR Journals
      • Arthritis & Rheumatology
      • Arthritis Care & Research
      • ACR Open Rheumatology
    • Rheumatology Image Library
    • Treatment Guidelines
    • Rheumatology Research Foundation
    • Events
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / The Battle with Insurance Companies to Obtain Prescriptions

The Battle with Insurance Companies to Obtain Prescriptions

March 17, 2018 • By Philip Seo

  • Tweet
  • Email
Print-Friendly Version / Save PDF

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.

You Might Also Like
  • Opinion: Insurance Companies Use Medically and Fiscally Irresponsible Formularies
  • Two Years of Helping Patients Obtain Prescriptions
  • Are Insurance Companies’ Medication Directives Fiscally, Medically Questionable?
Explore This Issue
March 2018
Also By This Author
  • Bending, Not Breaking

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:

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

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;

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

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;

ad goes here:advert-3
ADVERTISEMENT
SCROLL TO CONTINUE

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

Stmool / SHUTTERSTOCK.COM

Stmool / SHUTTERSTOCK.COM

Pages: 1 2 3 4 5 6 7 | Single Page

Filed Under: Legal, Legislation & Advocacy, Pharma Co. News, Rheuminations Tagged With: drug benefits, pharmacy benefit managers, prescriptionIssue: March 2018

You Might Also Like:
  • Opinion: Insurance Companies Use Medically and Fiscally Irresponsible Formularies
  • Two Years of Helping Patients Obtain Prescriptions
  • Are Insurance Companies’ Medication Directives Fiscally, Medically Questionable?
  • PRACTICE PAGE: The ACR Takes on Insurance Companies

ACR Convergence

Don’t miss rheumatology’s premier scientific meeting for anyone involved in research or the delivery of rheumatologic care or services.

Visit the ACR Convergence site »

American College of Rheumatology

Visit the official website for the American College of Rheumatology.

Visit the ACR »

Simple Tasks

Learn more about the ACR’s public awareness campaign and how you can get involved. Help increase visibility of rheumatic diseases and decrease the number of people left untreated.

Visit the Simple Tasks site »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2021 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.