#preauthorization

In the ever-evolving landscape of healthcare, prior authorization (PA) has become an essential aspect of the reimbursement process. While it serves as a mechanism to control costs and ensure appropriate care, the PA process has often been a source of frustration and inefficiency for healthcare providers. Let’s start by first understanding what the process of precertification means.

How Crucial is Pre-Authorization in a Medical Billing Service Company?

For a medical billing Service Company, pre-authorization is an important process to deal with.

There are many terms used for pre-authorization such as, “prior authorization”, “pre-certification”, “prior approval” etc.

Though these terms slightly vary, the process they refer to is all the same.

I have been dealing with getting approval for a prescription medication that is a covered benefit on our insurance policy. However, upon taking this to the pharmacy, I'm told they get a rejected "Not Covered Benefit" response and the entire cost of this very expensive medication will have to come out of my pocket. 

Rather than getting mad at the pharmacy, I tell them I will follow up with the insurance company. And so my twisted quest begins.

I call the insurance company, speak to the first rep who tells me its covered but she too gets a not covered when trying to find out what the co-pay will be. I now call and speak to four different departments.  Every customer service rep I speak with admits it is covered on our formulary. HOWEVER, after them saying that a form needed to be input into the system so we only have to pay the co-pay and not the outrageous price per pill, we're still waiting.

Then after 9 calls and 2 1/2 weeks, I called to check on the status only to discover they NOW need a preauthorization from the doctor's office to make sure its medically necessary.  Excuse me, I HAVE A PRESCRIPTION. Doesn't that make it medically necessary? Apparently not.

OK, I call the doctor's office, speak to his nurse who calls the insurance company, faxes them the form and wait, again, for another 5 days.

Call in again, speak to customer service who tells me first they don't see the preauthorization. So I basically go through this twisted tale of how long this has been going on and how frustrated I am (not with her) with the entire system which I am sure is designed to make someone give up so the insurance company does NOT have to pay for the coverage I'm paying for.

Feeling compassion for my frustration, she calls the appropriate department only to discover they have the preauthorization and they're working on it. Then says it takes 24-48 hours to get final approval. Final approval??? From Who???? 

Final approval remains a mystery. However, the customer service rep again takes pity on me and even though its already been over 24 hours, she will check on it in the morning AND IF she is successful, she will call me.

I am not hopeful but vow to call in AGAIN tomorrow. afternoon to speak to yet another customer service rep because you never get the same one twice AND they don't have direct lines so you can call back and speak to the same one. UGH!!!!

"Denial Reason: MEDICAL NECESSITY"

"Our clinical reviewer concluded the following: because of the details we received about your illness-chronic hepatitis C, genotype 1, liver status unknown. Medical studies show that Sovaldi may help when you have a certain liver condition (hepatitis C virus genotype 1, 2, 3 or 4); meet certain other conditions (18 years of age and older, compensated liver disease); and when used with certain other drugs (peginterferon alfa and ribavirin for genotypes 1 and 4; or ribavirin alonr if interferon cannot be used for medical reasons or for genotypes 2 and 3). Records we received do not show that you meet all of those conditions. We based this decision on you health plan’s prior authorization criteria for Sovaldi. 12 weeks is the duration of Sovaldi therapy."

I’m 23 (over 18). I have hepatitis C, genotype 1a. My liver is at F2 on the fibrosis scale (F0 being healthy, F4 meaning cirhossis). My viral count is ~1.1 million, BEYOND the upper tier. I was already approved for peginterferon and ribavirin by Anthem last week.

Am I missing something, aside from being treated?

Hopefully my doctor’s office figures something out, I’m already gearing up for a personal appeal.

Time to continue fighting.

- Brendan

EDIT: I've deduced that "compensated liver disease" has to be the roadblock. I'm unclear as to what specifically defines one as having said disease. Is my fibrosis enough to warrant the medication? Or do I have to actually have cirhossis? Symptoms even come into play. My biopsy should be sufficient, along with my viral load. I'm not sure if my doctor withheld that uknowing that it was a requirement of my insurance...or maybe he did and it wasn't enough.