Thursday, August 30, 2012

Prior Authorization: Optumrx

My colleagues tell me more and more prescriptions require prior authorization (PA) from the pharmacy benefit manager (PBM). My experience obtaining authorization for buprenorphine for a patient who has been using the drug for close to ten years may help illustrate the problems and opportunities. I last addressed the subject in 2009: Prescription Preauthorization: The New Medical Emergency.

Since we expected the last PA to expire in 90 days it took neither myself nor the patient by surprise when the pharmacy faxed me indicating I would have to call the PBM, Optumrx. As usual I asked the patient to sign my agreement indicating whether I should forward a copy of the medical record at no charge or make the call for my nominal prior authorization fee of $50. The patient chose the latter, and after confirming online payment I made the call.

I navigated the usual menus until the robot told me to enter the number "we have on file." This stumped me. Not only do I not know whether Optum wants my number or the patient's, but surely Optum knows better than I what numbers they keep in their files. Time to start hitting "0" on the keypad. This roused a human, and we got started.

We quickly established the identity of myself and the patient and the details of the prescription, all of which information I had already transmitted to the pharmacy. Then the representative asked for my fax number. Having no desire to receive information from this company via fax or any other medium, I refused. After placing me on hold to confirm that Optum can continue to function without my fax number (What if I do not have a fax number?) we proceeded. Next she asked me for a diagnosis and code. I provided the diagnosis but explained that I do not know the code.

Ultimately Optum approved reimbursement for another 90 days after about ten minutes during which I provided no information that I had not already provided to the pharmacy.

The question of whether PA saves health care dollars is beyond the scope of this post. The patient's contract with the payer determines the conditions of reimbursement. Unless the physician has contracted with the payer this remains between the patient and the payer.
  • The physician has no responsibility to obtain reimbursement for drugs.
  • The physician must provide a copy of the medical record at the patient's request.
  • The pharmacy benefit manager should determine whether to authorize reimbursement based on the record without talking to the physician or requiring the physician to complete a form.
  • PAs never constitute emergencies. They are only about money.
  • PBMs do not need the physician's fax number or tax ID number.
Some physicians attempt to obtain PA during patient encounters. While this allows the patient to know what transpires, in my opinion a physician who claims such an encounter as psychotherapy or medication management risks accusation of fraud. Better that the patient pay for the service directly, regardless of whether they attend.

With eRx and cloud-based electronic medical records (EMR) we have an opportunity to greatly increase the efficiency of PAs. Ideally, patient and physician should grant the PBM read-only access to the record, allowing such determinations without demanding further involvement of the physician. Until EMRs implement such capabilities eRx should alert the physician to the need for PA immediately on placing the order, allowing the physician to proceed immediately to an online form requesting necessary information.

Physicians afraid to say "no" to yet another intrusion on their time by companies happy to exploit us have enabled this monster. Only when the people who purchase insurance must shoulder the cost will the payers realize they must respect physicians' time.


  1. You Charge a FEE to make a phone call to request prior authorization ??!

    And you have the Chutzpah to refer to FIFTY DOLLARS as "Nominal"???

    I thought I had heard it all about M.D.s
    I have NEVER had an M.D. charge a fee to request a prior authorization and frankly I am appalled, regardless of whether you offer
    an alternative.

    I think you are exploiting your patients and that your charging a fee is exploitative
    and outrageous.

  2. You confirmed online payment before making the call ??!!


    I can't believe that you're not ashamed to put this in print.

    I think you're in the wrong profession, Dr.

  3. Yes, anon, a fee. This is how I make a living. I do not work for free. I have Chutzpah. And I refuse to increase my fee for clinical services to patients who pay cash, and other insured patients whose insurance companies do not require PA to subsidize the ones that do. I would prefer not to do them at all.

  4. I think his point is that the request for a PA is abuse by the insurance companies. His fee then might be an attempt to put in motion a patient revolt against this practice. I am a clinical social worker so I don't have any personal experience with this but I do hear how my clients struggle getting prescriptions because companies won't approve them.

  5. So anon, what makes you think doctors should perform unnecessary tasks like that for an insurance company, or even for a patient, for free? BTW, may patients are always free to choose another physician.

  6. As much as I dislike PAs I won't even call it abuse. My insurance premiums are outrageous. We have to do something to control medical care costs, but in this case it was wasteful.

  7. If you won't call it abuse - I will. There is absolutely no reason that any physician should waste their time to add legitimacy to an insurance company decision. It should be clear that the only reason we have prior authorization is for pharmacy benefit managers and insurance companies to make more money by refusing certain drugs. Their assumptions (all drugs in the same "class are the same" and "cheaper is equivalent" have been shown to be problematic. I think that most people don't realize how much time is wasted and all of that time is uncompensated. The following reference is fairly clear with an estimate of more than 20 hours per week per physician across all clinic staff.

    This is essentially free work for an insurance company. In what other business are you supposed to do that quantity of work for free? Furthermore it is also fairly well know that
    a significant amount of that work will be rejected and generate more work.

    You are correct that physician and their staff should not be in this loop of decisions that are in the best interest of the insurance company.

  8. I find it most remarkable that with all the hue and cry about "15 minute med checks" so many see it as just fine for physicians to waste time on PA that could be spent with the patient. We have only our selves to blame for failing to refuse, and the PA is only one of many ways in which we, and worthless "professional" associations like APA, have caved in to every manipulation from payers who have held their subscribers hostage most cynically.

    Perhaps I am in the wrong profession, but what if I have company, anon? We have a shortage of physicians now, and it will get worse with Obamacare. Who will take care of you while all those physicians in the "right profession" are doing PAs? And how many will enter medical school in the "right profession" to pursue the noble calling of wasting time on such administrative nonsense.

    Consider too that patients leave those of us who refuse to seek physicians willing to cave in, that latter group will eventually get overwhelmed.

  9. I actually give Optum props for even accepting a PA from Movie Doc. My Dad has health insurance and has me on it as well. I also qualify for Medicaid. I saw a psychiatrist under my father's insurance plan, paid a copay, and was prescribed a drug that required a PA. Medicaid will pay for my drugs for free, but this one needed a PA and they refused to accept a PA from my pdoc because he was not contracted with them...which is insane.

    Basically, I cannot get drugs approved by Medicaid unless I see a pdoc for free by using the taxpayers dollars. If I were to pay for Moviedoc's services, I would not be able to get medication requiring a PA.

    Now that is an insane use of PAs. God forbid disabled people go to doctors that won't contract with Medicaid. They might actually get appropriate treatment and medications.

  10. I found this I just had to spend 10 minutes to an inane prior auth for a medicine that is generic and was used to stabilize the patient during her hospitalization. During inpatient reviews, the insurance company knew full well what meds we used and approved them...but then the outpatient pharmacy carveout denied the script...and then a frantic call late last night by the girl's mother. A generic ... I actually chose the twice a day generic rather than the once a day brand name thinking access would have been easier even though compliance is typically better on any med that has less dosing!!!!!

  11. Bravo to Dr. George Dawson who sued MEDCO to reimburse him for his time doing these idioitc, waste of time PA's and WON!

    Dr. Dawson, or anyone else who has done this, can you please tell me to whom at these companies do you send your letter of intent informing them of your charges for doing their PA's? Do you have an acutal address for MEDCO, "Express" Scripts, etc?

    That was a brilliant move. Every practitioner needs to send them a similar letter.