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Thursday, March 19, 2009

It all depends on who you talk to.

So I'm filling a prescription for insulin. Simple right? Nope. Not anymore.

The prescription for NPH insulin, an intermediate acting insulin, had been filled and refilled many times for this person. But this time her insurance rejected the claim. Apparently, as the rejection showed on the computer screen, it needed a prior authorization. For those of you not yet aware of this little bug-a-boo, this is when the insurance company says that the doctor needs to make a written statement showing that the treatment is indeed necessary, otherwise the insurance will deny. This is usually encountered for high priced medications new to the market. Usually a drug like Coreg CR or Ambien CR, where the drug maker reformulates to make it last longer but where the real benefit comes to the company making the drug because it gives them another year of patent life. But for insulin? Why would insulin need a prior authorization?

So I call. I get this nice sweet voice on the line and I explain that there must be a mistake, that no company—not even an insurance company—would make insulin non-reimbursable. She said that, yes, she understood; but the rejection was correct. They really did require a prior authorization. What about other maker's of insulin? Wouldn't they be OK? Maybe it was just the particular insulin we were using that would be rejected. Unfortunately, no, she said. All insulin would be rejected—except for Novalog, she explained. Well, that wouldn't work, I told her. Novalog was a completely different type, and not interchangeable. Could she just check one more time?

Another problem for me was that she was just too sweet sounding to yell at. I, as other posts here have attested to, enjoy the odd phone call to protest the great injustices that insurance companies inflict on us. But here I was totally disarmed.

I make a note in the patient's file that she would need to get an authorization from her physician, and I faxed the request to the doctor's office.

Two days later I see that the insulin was dispensed and sold—without any authorization on the part of the insurance! One of my staff pharmacists, the day after I spoke with the insurance company, called them and, getting someone different, was told that Oh, it was just a mistake and just to re-run the claim and it would go right on through just as easy as you please.

Well, ain't that something. It just goes to show you that it depends on who you call. If you don't like the answer, just wait a bit and call back. The next person might actually know what they are talking about.

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