Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 Thanks Grace, but no money is necessary. I have already moved beyond the anger phase and into the acceptance phase regarding prior authorizations. However, just because I accept their reality does not mean I condone their use. I will continue to push against them or any other administrative hurdle which separate me from my patients. I find it ironic that at a time when most experts say we are going into a primary care crisis and desperately need primary care providers as that is the only way to curtail the spiraling costs of medicine, insurance companies insist on using provider abrasion as a short term cost saving measure. They (insurances and the government) should be doing everything in their power to keep us around until we are 80, not trying to burn us out by 35. Things will change because they have to…hopefully. From: [mailto: ] On Behalf Of pricklyfinger2007Sent: Sunday, June 10, 2012 1:51 AMTo: Subject: Re: Why PAs? john,i should cut and paste and send your post to the media. this requires more attention than that $5 bill for a wait type of thing.as far as i know, you get the $20 but i believe i already gave that out. ill see if i can get another $20 to give you on monday... ill give you another $10 if you can tell me where to take it from here.bravo my friend. i hope you are a governing board member of somewhere and you can push this so it will make a difference. ill just hang on to your coattail for now. im far too exhausted and angry with all these.g>> A couple of years after I opened my practice, BCBS in our area decided that> every CT needed prior authorization. We could do the prior auth on line and> get a response in a day or two or we could go through the phone tree and try> and get it approved in about 30 minutes or so. One day my nurse was gone and> I had a patient with RLQ abdominal pain. He was a healthy guy who was> generally pretty stoic. I was worried about an appendix, but knew it would> take 30 minutes to get the test approved. My schedule was light so I decided> to call for the approval. After a horrible process where the nurse was> initially reticent to give me the approval, the CT was done and it showed a> ruptured appendix. Scary. I called the person in charge of prior auths for> BCBS mid-Atlantic and fussed a bit and then listened for a while and these> were the conclusions I have come away with:> > 1) The purpose of prior auths is to increase barriers to care and> therefore decrease the ordering of the test/medication (provider abrasion)> in order to decrease costs.> > 2) The insurance companies historically do not have the technology (or> perhaps the willpower) to separate out the high utilizers of testing from> the rest and so they force everyone to go through these procedures> regardless if you order a CT scan every day or one a year.> > 3) The use of prior auths not only increases administrative liability> for the office (i.e. hours of uncompensated work), but it can also increase> clinical liability (see example above). As clinicians, we make decisions in> the blink of an eye, and yes, if faced with enough provider abrasion, we> will not order the necessary diagnostic test. The problem is that if the> test was not ordered, it is our fault not the insurance company's. After> all, the insurance company will claim that they never said not to do the> test, they just said they would not pay for it.> > 4) Increasing prior auths shifts costs in other ways. In the above> scenario, many docs would send the patient to the ER. In this case that is> appropriate, but some docs are now sending every patient needing a CT to the> ER so they do not have to deal with provider abrasion. Though this would> keep the office cost low, overall health care costs soar. But, these costs> are not recognized because they are noted as ER costs and not primary care> costs.> > 5) Even outside the realm of sending patients to the ER, the abrasion> is so abrasive to many primary care docs that they decide to retire or leave> medicine all together. This administrative " straw that breaks the camel's> back " results in fewer primary care docs and therefore increase costs.> > 6) Ultimately, prior auths fail to contain costs. Not only do docs> start sending their patients to the ER to get CTs or leave practice> altogether, but sooner or later every doctor's office learns what needs to> be said in order to get the approval done. So the entire process is one of> semantics. Once the correct words are known, those will be used over and> over again and the " abrasion " is minimized and utilization increases again.> (Note: though I am talking radiology prior auths, the same can be said for> prescriptions).> > Yes, there are docs out there who are prescribing too many name brand drugs,> or prescribing inappropriately, or ordering way too many tests. Those docs> need to be identified and educated to the fact that they are outliers.> However, erecting barriers to care which drive a wedge between doctors and> their patients is not the right solution. Prior auths increase office> administrative costs, increase clinical liability, decrease provider> satisfaction, and if evaluated critically, probably do not even work to> decrease overall costs. Better ways of encouraging good behavior (instead of> punishing " bad " ) need to be brought to the forefront.> > > > > > From: > [mailto: ] On Behalf Of Machata> Sent: Saturday, June 09, 2012 5:42 PM> To: > Subject: Why PAs?> > > > > > > Please send one green at your earliest convenience.> > Of course, many prior authorizations are a ridiculous waste of time and> energy, but I am an advocate of rational PAs. Too many doctors wantonly> order inappropriate tests and medications. Physicians bias toward errors of> commission and fear of making errors of omission leading to malpractice> suits, is part of the reason that Americans pay a higher percentage of our> gross domestic product than any nation yet we lag in quality measures across> the board.> > Choosing Wisely is an effort of nine medical societies representing 375,000> physicians to encourage physicians to be better stewards of finite health> care resources. In order to improve care we need to eliminate unnecessary> tests and procedures. Too often well meaning doctors order tests that do not> improve outcomes. A few examples:> a) Early imaging for back pain, which would resolve in a few weeks.> CT or MRI in patients with syncope and normal neurological exams.> c) Pre-operative chest x-rays in patients without clinical suspicion of> pathology.> > A member of a local Pharmacy and Therapeutics Committee of Neighborhood> Health Plan of Rhode Island, I am proud of a recent action. Two years ago we> altered our Suboxone PA prohibiting off label use- some physicians were> ordering it to treat pain. Over the past year NHPRI providers requested PAs> for Suboxone more than any other medication. Our review showed that all PAs> were approved. Our solution? We eliminated the prior authorization, thus> saving valuable physician and pharmacist time and energy.> > Any limitation of physician prerogative needs be rational. In the zero sum> game of American Medicine, physicians practice will be subjected to> constraints as long as many physicians fail to adhere to best practices> based on sound science.> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 I am you you G. PA= waste of time and it is an offense to the MD/DO/Provider. adolfo To: Sent: Sunday, June 10, 2012 9:53 AMSubject: Re: Why PAs? SCENARIO 1 :Prior authorization of bupropion SR. Already generic.1877******...bryan adams, bruno mars, rain and birds chirping in background,bruce springsteen and born in the usa....18 minutes...all our agents are busy...3 minutes...this call will be recorded (for my expletives probably)hello this is blah blahwhats your patient's name, member number, date of birthwhats your name, confirm your address, telefone (in case i hung up)what is this prescription for?Is BUP-PION used for the treatment of smoking?No.I'm sorry I didnt hear you.I said No.Ok. If BUP-pion is not used for treatment of smoking, we are authorizing this prescription until May 2013.Is there anything I...I hung up.Provider abrasion all 27 minutes. I could have seen a few patients for this time, saved a life or probably had used this time to eat my lunch.g Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 Hi Steve,I really don’t have too much of a problem with the concept of third party payers. My personal opinion is that health care is a right that everyone should enjoy, and I cannot see how it is possible to achieve that level of care without third party intervention. In fact, very few people in this country could afford comprehensive health care without insurance (note: though direct pay could potentially work for primary care office based services, all bets are off once someone leaves our “medical home” and enters the much more expensive larger world of medicine). I also don’t have too much of a problem with the reimbursement I receive for my services. Though many on this list serve will argue that I am devaluing myself, my reimbursement for a 99214 is around $100—not bad for 20-30 minutes worth of work.I do have a problem with the way we are paid and the subsequent unnecessary administrative hurdles which thrust their way between us and our patients. The payment system needs to be simple, transparent, and equitable enough to encourage more people to go into primary care. It should encourage quality over quantity, eliminate insurance “panels,” and pay for the intangibles that we do every day without weighing us down with onerous tasks that do not enhance the doctor-patient relationship. I do remain hopeful that some day we can change those aspects. We’ll see. From: [mailto: ] On Behalf Of drhorvitzSent: Sunday, June 10, 2012 12:32 PMTo: Subject: Re: Why PAs? We can talk about prior authorizations all we want. But the real problem is to third-party system and why doctors continue to put up with this abuse.Please don't come back with well that's the way it is and we have to accept it. Know that it's not the way it is. We have let it happen and we can change it.Stevestown>> A couple of years after I opened my practice, BCBS in our area decided that> every CT needed prior authorization. We could do the prior auth on line and> get a response in a day or two or we could go through the phone tree and try> and get it approved in about 30 minutes or so. One day my nurse was gone and> I had a patient with RLQ abdominal pain. He was a healthy guy who was> generally pretty stoic. I was worried about an appendix, but knew it would> take 30 minutes to get the test approved. My schedule was light so I decided> to call for the approval. After a horrible process where the nurse was> initially reticent to give me the approval, the CT was done and it showed a> ruptured appendix. Scary. I called the person in charge of prior auths for> BCBS mid-Atlantic and fussed a bit and then listened for a while and these> were the conclusions I have come away with:> > 1) The purpose of prior auths is to increase barriers to care and> therefore decrease the ordering of the test/medication (provider abrasion)> in order to decrease costs.> > 2) The insurance companies historically do not have the technology (or> perhaps the willpower) to separate out the high utilizers of testing from> the rest and so they force everyone to go through these procedures> regardless if you order a CT scan every day or one a year.> > 3) The use of prior auths not only increases administrative liability> for the office (i.e. hours of uncompensated work), but it can also increase> clinical liability (see example above). As clinicians, we make decisions in> the blink of an eye, and yes, if faced with enough provider abrasion, we> will not order the necessary diagnostic test. The problem is that if the> test was not ordered, it is our fault not the insurance company's. After> all, the insurance company will claim that they never said not to do the> test, they just said they would not pay for it.> > 4) Increasing prior auths shifts costs in other ways. In the above> scenario, many docs would send the patient to the ER. In this case that is> appropriate, but some docs are now sending every patient needing a CT to the> ER so they do not have to deal with provider abrasion. Though this would> keep the office cost low, overall health care costs soar. But, these costs> are not recognized because they are noted as ER costs and not primary care> costs.> > 5) Even outside the realm of sending patients to the ER, the abrasion> is so abrasive to many primary care docs that they decide to retire or leave> medicine all together. This administrative " straw that breaks the camel's> back " results in fewer primary care docs and therefore increase costs.> > 6) Ultimately, prior auths fail to contain costs. Not only do docs> start sending their patients to the ER to get CTs or leave practice> altogether, but sooner or later every doctor's office learns what needs to> be said in order to get the approval done. So the entire process is one of> semantics. Once the correct words are known, those will be used over and> over again and the " abrasion " is minimized and utilization increases again.> (Note: though I am talking radiology prior auths, the same can be said for> prescriptions).> > Yes, there are docs out there who are prescribing too many name brand drugs,> or prescribing inappropriately, or ordering way too many tests. Those docs> need to be identified and educated to the fact that they are outliers.> However, erecting barriers to care which drive a wedge between doctors and> their patients is not the right solution. Prior auths increase office> administrative costs, increase clinical liability, decrease provider> satisfaction, and if evaluated critically, probably do not even work to> decrease overall costs. Better ways of encouraging good behavior (instead of> punishing " bad " ) need to be brought to the forefront.> > > > > > From: > [mailto: ] On Behalf Of Machata> Sent: Saturday, June 09, 2012 5:42 PM> To: > Subject: Why PAs?> > > > > > > Please send one green at your earliest convenience.> > Of course, many prior authorizations are a ridiculous waste of time and> energy, but I am an advocate of rational PAs. Too many doctors wantonly> order inappropriate tests and medications. Physicians bias toward errors of> commission and fear of making errors of omission leading to malpractice> suits, is part of the reason that Americans pay a higher percentage of our> gross domestic product than any nation yet we lag in quality measures across> the board.> > Choosing Wisely is an effort of nine medical societies representing 375,000> physicians to encourage physicians to be better stewards of finite health> care resources. In order to improve care we need to eliminate unnecessary> tests and procedures. Too often well meaning doctors order tests that do not> improve outcomes. A few examples:> a) Early imaging for back pain, which would resolve in a few weeks.> CT or MRI in patients with syncope and normal neurological exams.> c) Pre-operative chest x-rays in patients without clinical suspicion of> pathology.> > A member of a local Pharmacy and Therapeutics Committee of Neighborhood> Health Plan of Rhode Island, I am proud of a recent action. Two years ago we> altered our Suboxone PA prohibiting off label use- some physicians were> ordering it to treat pain. Over the past year NHPRI providers requested PAs> for Suboxone more than any other medication. Our review showed that all PAs> were approved. Our solution? We eliminated the prior authorization, thus> saving valuable physician and pharmacist time and energy.> > Any limitation of physician prerogative needs be rational. In the zero sum> game of American Medicine, physicians practice will be subjected to> constraints as long as many physicians fail to adhere to best practices> based on sound science.> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 Grace, I loved s answers too as well as Sharon's about putting patient on the phone. I did that more before I had my part time nurse. I should return to it. At least one of my insurances has a web site for prior auths of radiological procedures AND list the criteria to get the approval. I'm going to try using that and see if that gets me through the hoops faster. It's should be much easier for me to read their list and determine how to fit the patients symptoms to that. (Yes, this is how others override the intent of the reasonable PA's and that's their abuse of the system but mine is to reduce this ridiculous appoved tactic of physician abrasion.) Maybe some of your insurances have the same option? To: Sent: Sunday, June 10, 2012 2:33 PM Subject: Re: Why PAs? dr.horvitz. true that. i didnt sign up for primary care to be canonized and i certainly should make it clear im not a masochist. but harping on 'not accepting third party payers' doesnt really solve the issue. example, the example i just gave. there is not a single reason that generic meds need to be prior authorized. escitalopram over fluoxetine or citalopram, to the extent that insurers dictate what patients should be on. so have you not dealt with prior authorizations at all, so what do your patients do? "here is this ct scan i need you to do, call your insurance company?" if I have difficulty in finding the right answers to give the almighty PA person to get an rx or test done, what do our patients have to go through? my laments: it's very clear. dr. brady has outlined very clearly what the problem is, but even then, it is not clear to everybody. grace Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 10, 2012 Report Share Posted June 10, 2012 1. Short term fix: The group could share criterion that we as individuals have collected over the years that insurances allow for various things. (although still have to jump through the hoops, but try to get patient to do so with you as back up). 2. Long term fix: Some of us have decided after how many years that the insurance industry is not going to change without a bigger incentive than they've had for the past 30 or so, so we left to try to help speed things along. Others are trying to fix from within, through organizations, hope, and other tactics. Gordon now essentially works for the insurance industry and is trying to change things from in there. Everyone has to decide what is best for their situation; the situations vary widely for lots of reasons. I just hate to see primary care docs feel so victimized and not recognize that they do have choices. I don't think that is good for the soul. SharonSharon McCoy MDRenaissance Family Medicine 10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com Grace, I loved s answers too as well as Sharon's about putting patient on the phone. I did that more before I had my part time nurse. I should return to it. At least one of my insurances has a web site for prior auths of radiological procedures AND list the criteria to get the approval. I'm going to try using that and see if that gets me through the hoops faster. It's should be much easier for me to read their list and determine how to fit the patients symptoms to that. (Yes, this is how others override the intent of the reasonable PA's and that's their abuse of the system but mine is to reduce this ridiculous appoved tactic of physician abrasion.) Maybe some of your insurances have the same option? To: Sent: Sunday, June 10, 2012 2:33 PM Subject: Re: Why PAs? dr.horvitz. true that. i didnt sign up for primary care to be canonized and i certainly should make it clear im not a masochist. but harping on 'not accepting third party payers' doesnt really solve the issue. example, the example i just gave. there is not a single reason that generic meds need to be prior authorized. escitalopram over fluoxetine or citalopram, to the extent that insurers dictate what patients should be on. so have you not dealt with prior authorizations at all, so what do your patients do? " here is this ct scan i need you to do, call your insurance company? " if I have difficulty in finding the right answers to give the almighty PA person to get an rx or test done, what do our patients have to go through? my laments: it's very clear. dr. brady has outlined very clearly what the problem is, but even then, it is not clear to everybody. grace Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 Part of the problem is that the supreme court vilified the PA practice when they said that patients couldn’t sue insurers for refusing to cover a service, medicine or test. They dumped it back in our laps by saying that they weren’t practicing medicine by the denials and that if the doctor still thought the care item was necessary, then the patient could pay for it themselves or the doctor could find an alternative. Thereby making us the bad guy in the patients eyes. Then you have patients who don’t understand what a PA is and why it is needed and don’t understand why you have prescribed a different medicine or procedure when their insurance is sending them letters telling them that what you have prescribed is going to cost them a lot of money or that there is a test that can be done that is cheaper. Have any of you ever read the letters sent to patients? Most of them are very degrading to health care providers (us) and make us out to be the bad guy. As long as this type of undermining is allowed to exist, the problem of PA’s and all the other 3rd party interference will continue. Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of pricklyfinger2007Sent: Sunday, June 10, 2012 2:33 PMTo: Subject: Re: Why PAs? dr.horvitz.true that. i didnt sign up for primary care to be canonized and i certainly should make it clear im not a masochist.but harping on 'not accepting third party payers' doesnt really solve the issue.example, the example i just gave. there is not a single reason that generic meds need to be prior authorized. escitalopram over fluoxetine or citalopram, to the extent that insurers dictate what patients should be on.so have you not dealt with prior authorizations at all, so what do your patients do? " here is this ct scan i need you to do, call your insurance company? " if I have difficulty in finding the right answers to give the almighty PA person to get an rx or test done, what do our patients have to go through?my laments: it's very clear. dr. brady has outlined very clearly what the problem is, but even then, it is not clear to everybody.grace Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 I have been part of systems (both as provider and as patient) that had " gold carded " doctors for automatic approval (for certain things at least) after they proved their cost-effectiveness. Why this isn't more widely used now may point to a profit motive or to the difficulty of naming some providers as being in " the bottom tier. " Not sure which. Sharon Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com I agree with all 's points except #2. " 2) The insurance companies historically do not have the technology (orperhaps the willpower) to separate out the high utilizers of testing from the rest and so they force everyone to go through these proceduresregardless if you order a CT scan every day or one a year. " The insurance companies have the technology to identify the high utilizers. For many years, I was consistently given annual reports stating my costs for patient care were below average, and my outcomes, preventative measures, etc were above average. Yet, despite my requests to be " gold carded " , I have to go thru the same prior auth as everyone else. It is not that they lack the willpower either. The goal, as you say, is to increase provider abrasion for all of us and not just the " overutilizers " . A buck saved is still a buck saved. Mike Safran Re: Why PAs? Posted by: " Dr. Brady " drbrady@... famdocman3 Sat Jun 9, 2012 7:38 pm (PDT) A couple of years after I opened my practice, BCBS in our area decided thatevery CT needed prior authorization. We could do the prior auth on line andget a response in a day or two or we could go through the phone tree and try and get it approved in about 30 minutes or so. One day my nurse was gone andI had a patient with RLQ abdominal pain. He was a healthy guy who wasgenerally pretty stoic. I was worried about an appendix, but knew it would take 30 minutes to get the test approved. My schedule was light so I decidedto call for the approval. After a horrible process where the nurse wasinitially reticent to give me the approval, the CT was done and it showed a ruptured appendix. Scary. I called the person in charge of prior auths forBCBS mid-Atlantic and fussed a bit and then listened for a while and thesewere the conclusions I have come away with:1) The purpose of prior auths is to increase barriers to care and therefore decrease the ordering of the test/medication (provider abrasion)in order to decrease costs.2) The insurance companies historically do not have the technology (orperhaps the willpower) to separate out the high utilizers of testing from the rest and so they force everyone to go through these proceduresregardless if you order a CT scan every day or one a year.3) The use of prior auths not only increases administrative liabilityfor the office (i.e. hours of uncompensated work), but it can also increase clinical liability (see example above). As clinicians, we make decisions inthe blink of an eye, and yes, if faced with enough provider abrasion, wewill not order the necessary diagnostic test. The problem is that if the test was not ordered, it is our fault not the insurance company's. Afterall, the insurance company will claim that they never said not to do thetest, they just said they would not pay for it.4) Increasing prior auths shifts costs in other ways. In the above scenario, many docs would send the patient to the ER. In this case that isappropriate, but some docs are now sending every patient needing a CT to theER so they do not have to deal with provider abrasion. Though this would keep the office cost low, overall health care costs soar. But, these costsare not recognized because they are noted as ER costs and not primary carecosts.5) Even outside the realm of sending patients to the ER, the abrasion is so abrasive to many primary care docs that they decide to retire or leavemedicine all together. This administrative " straw that breaks the camel'sback " results in fewer primary care docs and therefore increase costs. 6) Ultimately, prior auths fail to contain costs. Not only do docsstart sending their patients to the ER to get CTs or leave practicealtogether, but sooner or later every doctor's office learns what needs to be said in order to get the approval done. So the entire process is one ofsemantics. Once the correct words are known, those will be used over andover again and the " abrasion " is minimized and utilization increases again. (Note: though I am talking radiology prior auths, the same can be said forprescriptions).Yes, there are docs out there who are prescribing too many name brand drugs,or prescribing inappropriately, or ordering way too many tests. Those docs need to be identified and educated to the fact that they are outliers.However, erecting barriers to care which drive a wedge between doctors andtheir patients is not the right solution. Prior auths increase office administrative costs, increase clinical liability, decrease providersatisfaction, and if evaluated critically, probably do not even work todecrease overall costs. Better ways of encouraging good behavior (instead of punishing " bad " ) need to be brought to the forefront. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 I didn't realize the supreme court did this. I haven't seen the letters. Don't want to with your warning! I see enough letters when patients come in demanding that I code a visit differently so they don't have to pay a co-pay. They tell patients I did it wrong! The same ones who when I call for assistance in getting a visit paid for tell me "we can't tell you how to code". Didn't know about the gold standard either! But my numbers are too low to be able to ever get that kind of service either. To: Sent: Sunday, June 10, 2012 9:24 PM Subject: RE: Re: Why PAs? Part of the problem is that the supreme court vilified the PA practice when they said that patients couldn’t sue insurers for refusing to cover a service, medicine or test. They dumped it back in our laps by saying that they weren’t practicing medicine by the denials and that if the doctor still thought the care item was necessary, then the patient could pay for it themselves or the doctor could find an alternative. Thereby making us the bad guy in the patients eyes. Then you have patients who don’t understand what a PA is and why it is needed and don’t understand why you have prescribed a different medicine or procedure when their insurance is sending them letters telling them that what you have prescribed is going to cost them a lot of money or that there is a test that can be done that is cheaper. Have any of you ever read the letters sent to patients? Most of them are very degrading to health care providers (us) and make us out to be the bad guy. As long as this type of undermining is allowed to exist, the problem of PA’s and all the other 3rd party interference will continue. Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of pricklyfinger2007Sent: Sunday, June 10, 2012 2:33 PMTo: Subject: Re: Why PAs? dr.horvitz.true that. i didnt sign up for primary care to be canonized and i certainly should make it clear im not a masochist.but harping on 'not accepting third party payers' doesnt really solve the issue.example, the example i just gave. there is not a single reason that generic meds need to be prior authorized. escitalopram over fluoxetine or citalopram, to the extent that insurers dictate what patients should be on.so have you not dealt with prior authorizations at all, so what do your patients do? "here is this ct scan i need you to do, call your insurance company?" if I have difficulty in finding the right answers to give the almighty PA person to get an rx or test done, what do our patients have to go through?my laments: it's very clear. dr. brady has outlined very clearly what the problem is, but even then, it is not clear to everybody.grace Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 11, 2012 Report Share Posted June 11, 2012 http://www.globalethics.org/newsline/2004/06/28/patients-cannot-sue-hmos-for-denying-prescribed-care-supreme-court/ This is a link to information on this decision And for a much more lengthy legal brief on the topic check out this link. Very interesting reading. And enlightening as to why this problem continues to snowball. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449155/ Hope you find this enlightening. Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of MyriaSent: Monday, June 11, 2012 5:54 AMTo: Subject: Re: Re: Why PAs? I didn't realize the supreme court did this. I haven't seen the letters. Don't want to with your warning! I see enough letters when patients come in demanding that I code a visit differently so they don't have to pay a co-pay. They tell patients I did it wrong! The same ones who when I call for assistance in getting a visit paid for tell me " we can't tell you how to code " . Didn't know about the gold standard either! But my numbers are too low to be able to ever get that kind of service either. To: Sent: Sunday, June 10, 2012 9:24 PMSubject: RE: Re: Why PAs? Part of the problem is that the supreme court vilified the PA practice when they said that patients couldn’t sue insurers for refusing to cover a service, medicine or test. They dumped it back in our laps by saying that they weren’t practicing medicine by the denials and that if the doctor still thought the care item was necessary, then the patient could pay for it themselves or the doctor could find an alternative. Thereby making us the bad guy in the patients eyes. Then you have patients who don’t understand what a PA is and why it is needed and don’t understand why you have prescribed a different medicine or procedure when their insurance is sending them letters telling them that what you have prescribed is going to cost them a lot of money or that there is a test that can be done that is cheaper. Have any of you ever read the letters sent to patients? Most of them are very degrading to health care providers (us) and make us out to be the bad guy. As long as this type of undermining is allowed to exist, the problem of PA’s and all the other 3rd party interference will continue. Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of pricklyfinger2007Sent: Sunday, June 10, 2012 2:33 PMTo: Subject: Re: Why PAs? dr.horvitz.true that. i didnt sign up for primary care to be canonized and i certainly should make it clear im not a masochist.but harping on 'not accepting third party payers' doesnt really solve the issue.example, the example i just gave. there is not a single reason that generic meds need to be prior authorized. escitalopram over fluoxetine or citalopram, to the extent that insurers dictate what patients should be on.so have you not dealt with prior authorizations at all, so what do your patients do? " here is this ct scan i need you to do, call your insurance company? " if I have difficulty in finding the right answers to give the almighty PA person to get an rx or test done, what do our patients have to go through?my laments: it's very clear. dr. brady has outlined very clearly what the problem is, but even then, it is not clear to everybody.grace Quote Link to comment Share on other sites More sharing options...
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