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Report from front lines of medicine

March 18, 2012
The Herald-Star

To the editor:

Most days I thoroughly enjoy practicing medicine, despite the tons of paperwork, poor reimbursement from insurance companies and threat of suit from malpractice attorneys. For me, the patients that I take care of make my job professionally challenging and personally satisfying.

The other day I spent 20 minutes on the phone with an insurance company/pharmacy benefit program getting a medication authorized for a patient. I am a technically savvy physician who attempted to use my electronic medical record system to ensure that the medication was on the patient's approved formulary. The government now also mandates I do this through its "meaningful use" legislation. After I determined electronically that the medication was "on formulary," I electronically sent the prescription to the pharmacy. The patient (not the pharmacy) informed me the medication was denied. I would have appreciated a call from the pharmacy and an attempt to get it authorized working with them. I then called the pharmacy and they couldn't provide me with any details about why the prescription was not covered.

I called Medco (the insurance company's contracted prescription benefit administrator). After a 10-minute phone tree was unable to process the patient's ID number, my physician identification information or find the patient by name and DOB, I finally got a live representative. After again giving him all pertinent identification information, he did confirm the medication was denied ("per the patient's plan"- no reason.) I began the preauthorization process over the phone and he then asked me one clinical question related to the prescription which I answered.

Voila! Immediate approval. When I asked why the pharmacy couldn't have been given that simple questionnaire, he informed me that he "just works here" and doesn't make the rules.

I am frustrated on a daily basis by the inefficiency and lack of common sense implemented by insurance companies that have become the norm in my effort to provide good, and often cost-effective, care to patients. In that 20 minutes spent jumping through hoops I could have actually been productive. The insurance companies assume (and rightly so) that most of us won't pursue the denials, even to find out why it was denied. Pursuing denials is time-consuming, often counterproductive and not reimbursable. Unlike attorneys, doctors do not get paid for time spent.

Each day I remind myself why I decided to practice medicine and tell myself, "illegitimi non carborundum." Don't let the bastards grind you down.

Dr. Rachel S. Gilman


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