What started as a simple tool to cut costs has exploded into a tangled mess of red tape – delaying care, wasting billions and leaving doctors and patients under piles of paperwork.
As a patient, several of my medicines need prior authorization. I used to be in a yearly schedule where my doctor had to send in a prior authorization once a year. Last year, when it was time to send in the yearly prior authorization, I received only 3 months of approval. Since then, my doctor must send in a PA every 3 months.
I think they are hoping the extra paperwork will lead my doctor to prescribe a different, cheaper medicine.
Well written and thought-provoking. How do we get the right Congressional people focused on this and find a better solution than Prior Authorization as it exists today?
Ask all Senators and Representatives to co sponsor the reintroduction of Medicare For All act in this current 119th Congress. This bill cares for the whole body.
OMG! I have been trying to refill my rescue inhaler since Saturday. I stopped to pick it up Saturday and my coupon card had expired (so it would cost me $0). I came back Sunday, dropped off another coupon card, which the pharmacy was having trouble with on the website. We need to call the coupon company, but can't on the weekend, we'll call on Monday.
On Tuesday, I stopped to pickup it up but found out that the coupon card only works if my insurance "approves" the drug. They need to get a prior authorization from the prescribed.
After multiple messages to providers and multiple phone calls, the prior authorization has been completed and sent to insurance.
Of course, I have to wait for a LETTER from my insurance saying that this inhaler is covered.
Without insurance, my rescue inhaler costs ~$700! While talking to insurance they said the PA completed in December when I initially filled my prescription had been denied. The coupon card still paid for it (which has since changed). The reason it was denied: they didn't use my insurance companies PA form, they used one that I assume most pharmacies use. 🤪
Why you always dissing on boomers? Why you say we should go after exorbitant provider reimbursement instead of insurance corporations and other payors? Just to be contrary?
Have you never looked at your medical bills? Provider portion is always a tiny fraction of the total surgery bill.
Do you think paying your surgeon $395 for doing an appendectomy is too much?
Let’s do some insurance vocabulary: a provider is a physician, nurse practitioner or physician assistant. A professional who bills under ICD10 diagnostic codes for office visits or procedures.
You’re mistakenly including hospitals and surgery centers in the term provider. These are distinct entities that bill patients and insurance directly for the hospital portion and the facilities charges for a procedure separately. They are the ones who bill exorbitantly, and drive up the price of healthcare in the US. This is where you see the variation in charges for identical procedures, inflated already by greed, allowed by statute to increase with inflation, and differing based on reputation. (MD Anderson Cancer Center can charge INSCOs more than a community hospital for the same procedure code).
These entities are able to negotiate with INSCOs and CMS based on the qualities you list. These entities may own physician practices, and can therefore tack on extra facility fees that independent physicians practices cannot. These do not flow to the providers who actually do the care.
I don’t know where you got the notion that physicians can negotiate with INSCOs based on their expertise, but that stopped ~2010. In independent physician practices, they tell US what we’re getting paid, “take it or leave it”, which is why you’ll find physicians with expertise don’t take certain plans ( aren’t “in network” for low paying plans), and newer physicians take everything until they build their practice and can discard the poorly paying plans.
Physician/Provider reimbursement is not tied to any measure of inflation, and is stated as a “percentage of Medicare” in our INSCO contracts. Today, a good “plan might reimburse 130% of Medicare fees, and a bad plan only reimburse 90% of the Medicare allowed charges. That’s what we mean when we say everything is “tied to Medicare”. Since provider reimbursement is not tied to inflation, and since it has not been increased in 25+ years, we have both an inflationary decrease in provider reimbursement and a capitalistic decrease in provider reimbursement over the same time frame that hospital reimbursement has increased dramatically. Example: global maternity care used to reimburse the OBGyn ~3800$ from first OB visit to 6 weeks postpartum (including delivery), now ~2800$ is about average, and “bad” plans pay as low as 1700$. This decrease is in the face of wildly increased costs of delivery for the patients- who may pay upwards of 15k to the hospital for a normal delivery.
Such a complicated calculus, designed by INSCO and hospital wonks colluding to obscure the inner workings of the American healthcare economy. The opposite of transparency, and a huge source of fraud, waste and abuse.
I have a feeling you and I agree on most things, but you come from a different point of view more sympathetic to INSCOs. Maybe work for a third party payor?
I still want to hear why you blame the boomers for our healthcare economy woes, and state that our problems will be solved once boomers die off in a decade. It should be interesting to hear you defend that statement.
I agree that it is often a waste of time seeking preauthorization to see a specialist. These are hidden costs that delay timely care for patients.
As a patient, several of my medicines need prior authorization. I used to be in a yearly schedule where my doctor had to send in a prior authorization once a year. Last year, when it was time to send in the yearly prior authorization, I received only 3 months of approval. Since then, my doctor must send in a PA every 3 months.
I think they are hoping the extra paperwork will lead my doctor to prescribe a different, cheaper medicine.
Well written and thought-provoking. How do we get the right Congressional people focused on this and find a better solution than Prior Authorization as it exists today?
Ask all Senators and Representatives to co sponsor the reintroduction of Medicare For All act in this current 119th Congress. This bill cares for the whole body.
The goal is to kick the can down the road and for people to give up and go away, and die.
OMG! I have been trying to refill my rescue inhaler since Saturday. I stopped to pick it up Saturday and my coupon card had expired (so it would cost me $0). I came back Sunday, dropped off another coupon card, which the pharmacy was having trouble with on the website. We need to call the coupon company, but can't on the weekend, we'll call on Monday.
On Tuesday, I stopped to pickup it up but found out that the coupon card only works if my insurance "approves" the drug. They need to get a prior authorization from the prescribed.
After multiple messages to providers and multiple phone calls, the prior authorization has been completed and sent to insurance.
Of course, I have to wait for a LETTER from my insurance saying that this inhaler is covered.
Without insurance, my rescue inhaler costs ~$700! While talking to insurance they said the PA completed in December when I initially filled my prescription had been denied. The coupon card still paid for it (which has since changed). The reason it was denied: they didn't use my insurance companies PA form, they used one that I assume most pharmacies use. 🤪
I'm so tired of fighting for everything!!
Jerry. Your way of communicating is so contrary.
Why you always dissing on boomers? Why you say we should go after exorbitant provider reimbursement instead of insurance corporations and other payors? Just to be contrary?
Have you never looked at your medical bills? Provider portion is always a tiny fraction of the total surgery bill.
Do you think paying your surgeon $395 for doing an appendectomy is too much?
Jerry, Jerry
Let’s do some insurance vocabulary: a provider is a physician, nurse practitioner or physician assistant. A professional who bills under ICD10 diagnostic codes for office visits or procedures.
You’re mistakenly including hospitals and surgery centers in the term provider. These are distinct entities that bill patients and insurance directly for the hospital portion and the facilities charges for a procedure separately. They are the ones who bill exorbitantly, and drive up the price of healthcare in the US. This is where you see the variation in charges for identical procedures, inflated already by greed, allowed by statute to increase with inflation, and differing based on reputation. (MD Anderson Cancer Center can charge INSCOs more than a community hospital for the same procedure code).
These entities are able to negotiate with INSCOs and CMS based on the qualities you list. These entities may own physician practices, and can therefore tack on extra facility fees that independent physicians practices cannot. These do not flow to the providers who actually do the care.
I don’t know where you got the notion that physicians can negotiate with INSCOs based on their expertise, but that stopped ~2010. In independent physician practices, they tell US what we’re getting paid, “take it or leave it”, which is why you’ll find physicians with expertise don’t take certain plans ( aren’t “in network” for low paying plans), and newer physicians take everything until they build their practice and can discard the poorly paying plans.
Physician/Provider reimbursement is not tied to any measure of inflation, and is stated as a “percentage of Medicare” in our INSCO contracts. Today, a good “plan might reimburse 130% of Medicare fees, and a bad plan only reimburse 90% of the Medicare allowed charges. That’s what we mean when we say everything is “tied to Medicare”. Since provider reimbursement is not tied to inflation, and since it has not been increased in 25+ years, we have both an inflationary decrease in provider reimbursement and a capitalistic decrease in provider reimbursement over the same time frame that hospital reimbursement has increased dramatically. Example: global maternity care used to reimburse the OBGyn ~3800$ from first OB visit to 6 weeks postpartum (including delivery), now ~2800$ is about average, and “bad” plans pay as low as 1700$. This decrease is in the face of wildly increased costs of delivery for the patients- who may pay upwards of 15k to the hospital for a normal delivery.
Such a complicated calculus, designed by INSCO and hospital wonks colluding to obscure the inner workings of the American healthcare economy. The opposite of transparency, and a huge source of fraud, waste and abuse.
I have a feeling you and I agree on most things, but you come from a different point of view more sympathetic to INSCOs. Maybe work for a third party payor?
I still want to hear why you blame the boomers for our healthcare economy woes, and state that our problems will be solved once boomers die off in a decade. It should be interesting to hear you defend that statement.