Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


An Evaluation of Prescription Insurance Coverage Inconsistencies Prior Authorization Does Not Mean Approval.

Crate2,  Dawn C., Albert1,  Daniel A.

Dartmouth-Hitchcock Med Ctr, Lebanon, NH
Dartmouth-Hitchcock Medical Center

Purpose:

To evaluate the medication prior authorization process for rheumatology prescriptions.

Method:

Cases were acquired through the prescription insurance coverage prior authorization process in the Rheumatology Section between March 1, 2010 and June 18, 2010. Each case was charted in a table to reflect the length of time it took to receive the outcomes including:

specific medication prior authorization

patient diagnosis

diagnosis as on or off label (using FDA standards)

whether the insurance company requested a peer to peer or step therapy (alternate medication)

number of times insurance company was contacted before outcome was given

outcome and reason for outcome

Results:

The Dartmouth-Hitchcock Rheumatology Clinic referred 65 patients for insurance carrier prior authorization between March 1, 2010 and June 18, 2010. This population represents 16% of the total number of patients seen in clinic during that timeframe. The prescription prior authorization process averaged to two hours per patient from initial referral to completion. Time spent per request ranged from twenty minutes to three hours, 100% of the cases needed more than one phone call to determine the outcome,62.5% of the total cases required a peer to peer (medical provider required to contact an insurance company physician), 75% of the cases were approved. Out of the 75% approved, 12.5% were found to not need a prior authorization, 50% of the cases that were approved were denied once the claim was submitted through billing. These cases are now in an appeal process. 37% of the cases were for off label use and out of those 50% were approved then denied when the claim was submitted. Categories of problems include:

1) FDA approved medications not covered

2) Insurance company representative conveyed incorrect information about coverage

3) Approval given then subsequently withdrawn (denied)

4) Medication denied then approved without appeal

5) Insurance company confused about their own appeal process

6) Pharmacy told patient prior approval needed when it wasn't and vice versa.

Conclusion:

There is no consistent prescription prior authorization process within the insurance company industry. The lack of standardization creates problems such as an approval is initially granted and then upon review the approved medication coverage is denied. Insurance carriers also may initially approve a medication but then require reauthorization at the time of renewal. Patients are frequently required by the insurance company to trial one or more medications before approval will be given for the prescribed treatment plan.

The current lack of process amongst the insurance company industry for prescription medication prior authorization is time consuming, inefficient and costly for physicians, clinic staff, patients and insurance carriers.

To cite this abstract, please use the following information:
Crate, Dawn C., Albert, Daniel A.; An Evaluation of Prescription Insurance Coverage Inconsistencies Prior Authorization Does Not Mean Approval. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1537
DOI: 10.1002/art.29303

Abstract Supplement

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