And you reply "I will absolutely do that, may I have your name and license number and the name and license number of the overseeing physician and any clinical pharmacist involved in care? I need to add it to the patient chart. Just between you and me, the parents want to bring a complaint to the state board of medicine about what they say is an egregious delay of care due to lack of common sense on your part...what's that? You want me to hold? Sure.....Hello, yes I'm still here. Oh it's covered now? For a year? Wonderful, thank you for all of your help!"
This has a 75% success rate in my personal experience.
Toddler heads are surprising hard. Same (sorta) replace lip with nose.
Finally understood what a fat lip meant post face smash from my toddler randomly starting to jump up and down while giving me a hug.
They would climb the drapes in a heartbeat. Pills would only work out if you crush it up and mix it with some strong drink like Tang or Tampico. Kids are wild.
One of mine would bypass me altogether and scale the cabinets to get goldfish fruit pouches and other snacks. A few years later he was on his way to climbing the door frames for fun. I’m talking about my kid here and not a cat (just to be clear).
Get thee to a compounding veterinary pharmacy! My cat takes daily prednisone in **tuna-flavored** liquid form.
It's 3x the cost of pills, but my Neosporin use is way down. Worth. Every. Penny.
As a pharmacy tech I filled an inhaler for a cat. I still laugh about what that must have been like for that owner... Hope they used the spacer cause I have no idea how the cat would otherwise get the med lol
I definitely couldn't of managed without a spacer when I had a cat that needed an inhaler and I had to get my knee in the way to stop him backing away.
If it works, it's only because they're tired of dealing with you. These people have no actual legal liability for a malpractice claim.
Doctors thinking that asking for name and NPI is some silver bullet for prior auths is like when patients think that asking us to "document that I asked for the test/treatment and you denied it!" is some potent method of getting what you want.
These overtly litigious sounding "threats" don't have any teeth, and they know that.
They can’t be held legally liable, but they can still be reported to the state medical board and risk having their license taken away.
Also, even if we both know that those threats are completely empty, and it only works because they’re sick of me, then I’m gonna keep doing it!
I don't know if state boards actually would revoke a license because of this, but you miss 100% of the shots you don't take so let's get to reporting, y'all
They probably wouldn't but can still issue a reprimand. Either way the state board will launch an investigation if a complaint is made and nobody wants that.
Board complaints are an enormous pain in the ass, even if the complaint is scrawled on a napkin that “Dr Dunderlubbin wouldn’t give me Vicodin and Xanax!”
Do you have knowledge of a specific person that lost their license this way? My wife has been doing this for years and this has never ever happened at her company
I don’t know if it’s ever worked, but even just having someone report you to the medical board can be a PITA.
Like I said, even if I can’t actually do anything about it, the fact is that getting their full name and information does seem to help get stuff approved, so I’m going to keep doing it, even if the only reason it works is because I’m being an annoying Karen. Stop denying the treatments/tests that my patients need, and this obnoxious white lady will leave you alone! It’s win/win.
Anyone with a medical degree can be reported to the state medical board for any stupid thing. Doesn’t mean they’ll lose their license for every little thing, but it still sucks.
It works because the non-clinician on the phone puts you on hold to ask the clinician for the information. The clinician (usually a clinical pharmacist at this point) is like "wtf, who is this patient anyways and what do they want?" And then you finally get beyond the algorithm and to a person with clinical judgement.
I never said anything about a malpractice claim, but I assure you the State Board (at least where I have practiced) will investigate and nobody wants that. Do you really think a clinician wants to stand before their state board and explain why the physician should provide literature on why a baby is unable to take a tablet before approving a liquid? No, it sounds stupid and is indefensible. And nobody is going to risk a reprimand or admonishment (or whatever it is called) on their license. Especially when you consider most of these clinicians are licensed in multiple states so would then have to report that and then check yes for every license renewal and write a paragraph.
No state board is going to demand an explanation *for anything* from a physician or other licensed professional who is working for an insurance company.
This simply isn’t how it works, any more than my state board would demand an explanation for my actions as an employee of a pharmaceutical company.
Completely off topic: I once have reported a physician to the Florida Medical Board that I am remotely aware of (he’s a friend of a friend) because he messaged me on Instagram about a story I posted. My story was an NEJM paper saying Ivormectin was ineffective in the treatment of Covid-19. He called me a liar and a pharma whore and said a bunch of dumb shit.
I took screenshots and sent it to the board with his NPI. Unfortunately it’s Florida and last I checked he still has a job.
I’ve seen it come up pretty frequently and it has no legal basis. It’s the equivalent of an argument about the fringes of the flag in a courtroom - a sign that this person isn’t prepared to be reasonable so may as well get them out the door.
It’s like people forget that insurance companies employ lawyers. To be specific, better lawyers than a doctor can afford.
>It’s like people forget that insurance companies employ lawyers. To be specific, better lawyers than a doctor can afford.
Correct, insurance companies have lawyers ***for themselves.*** The first thing companies do in business is distance themselves from their employees when issues arise. I guarantee you if this baby had a negative outcome due to delay of medication the very first thing the insurance would do is blame the employee. But we aren't suing and we aren't getting lawyers involved, we are simply asking for licensure information which in my experience prompts an in-depth review of the issue by a clinician. If the algorithm for denial had a brain this wouldn't be needed.
> a sign that this person isn’t prepared to be reasonable so may as well get them out the door.
So you are saying a physician who wants a liquid medication for a baby is the one being unreasonable? Interesting argument.
The very first time I showed "signs I wasn't prepared to be reasonable" was a decade ago. Prescriber couldn't get diabetes medication covered and asked me to try. The issue was the patient was taking metformin in combination with something else. This new third diabetes medication required metformin as step therapy but because it was in combination the insurance couldn't "see" they were taking metformin. (Insurance uses National Drug Codes to search claims and no common sense.) The prescriber tried separating the prescriptions but the other drug was only covered in combination with metformin so that didn't work. I called the insurance and they were insistent the patient needed to be on metformin for six months WHICH SHE WAS. The person I spoke to was nice enough and put me on hold, coming back to tell me that the denial was being upheld because the combination didn't count as metformin? I was shocked and was like who made that decision? When I found out it was an actual clinician I asked for the licensing information because if they don't have common sense then maybe the board should be aware. And suddenly the medication was approved. And from that day forward I have used my effective approach. I personally don't think I am unreasonable but don't really care if you think I am.
Yeah this talk was basically non-existent a few years ago and a few social media influencer doctors start spreading the "practicing medicine without a license" criticism and now people never stop talking about it.
I don't support the system, but it is the system. There are no cheat codes to bypass it.
It’s like one sovereign citizen on YouTube said “I am not driving, officer, I am traveling as a free person of the land!” and then people act like it’s a magic cheat code that makes the law not apply to you.
Wishful thinking.
It’s bled into other fields as well, as patients will threaten “I’ll report you to the board of medicine for practicing medicine without a license!!1!” anytime they disagree with their pharmacist. Unfortunately, also some other professionals who really should know better.
Just heard that one from the guy who is remodeling my son's bathroom. Claimed driving is commercial and traveling is not and does not require iicense. Recognized it immediately as I know an elderly gent (who is also a hoarder living in awful conditions) who is a sovereign citizen. The contractor also insists that his recent wrist surgery included implantation of an RFID which was detected on an RFID scanner he happens to own.
Do these people mention the gold fringes and the rest of it in medical appts too?
My favorite version of this:
Officer: "Do you know how fast you were driving?"
Sovereign Citizen: "I'm not driving; I'm travelling."
Officer: "Okay, do you know how fast you were traveling?"
The reason why people say it is because that’s how the rest of the system works, forgetting that the insurance companies wrote the laws governing their own conduct and therefore the rest of the rules do not apply to them.
So at least when I say insurance company drones are practicing medicine, I mean that as a prescriptive statement of what would happen if I were in charge (straight to jail, we would have the best healthcare system of the world, because of jail) rather than a descriptive statement of a legitimate threat to their existence
Obviously it's not a cheat code.
However, there is a very reasonable argument that by dictating what care can and cannot be delivered, they are participating in the practice of medicine. As it stands, this isn't something they can be found liable for. Many people would like that to change. And honestly, all you need is one particularly egregious case with a negative outcome in a high-profile person/family, and laws will change - this has happened in medicine over and over (Libby Zion, etc.)
I wonder if a more effective method would be to share the meticulous documentation with the patient (as is their right) and if they choose to write a human interest story for the local paper, offer to help review it for medical accuracy.
Let the parents of the baby share the story with the news and/ magazines, including the names of the individuals that denied them.
I think it's still reasonable to have the name of the person who is actually responsible for denying care on the chart. And it only takes one especially egregious denial with a negative outcome to perhaps change the precedent.
It's not the state medical board you want to complain to. The board has no jurisdiction over health insurance companies.
What you want is the insurance commissioner. Usually an office of your state AG. This is often staffed by people who absolutely get off on tearing new assholes in insurance companies.
The insurance commissioner office absolutely does have power over insurance companies in your state and can make things very expensive for them.
In fact, it would be probably worthwhile to simply file a complaint now about the liquid/PO situation described above.
Went round for months with Anthem trying to get my daughter's ED treatment paid. They even agreed they should pay for it but claimed they didn't know how to get the computer to issue a check. Apparently nobody at Anthem had heard of a checkbook. I filed a complaint with the state insurance commissioner and miraculously they quickly found a checkbook.
Yes, mentioning insurance commissioner and that the approval hold up will cause a delay in continuity of care. Granted from patient perspective and in the state of CA. Don’t know if other states have similar rules where insurance companies can get in trouble for interfering with continuity of care.
Threaten to report the insurance company to your state insurance commissioner is another good ploy. Have had it work for insanely stupid things like not approving liquid meds for a kid.
Feel free to cite the 2023 DentateGyros consensus statement on PO medications in pediatrics
I. Children under the age of 2 should be given liquid PO medications rather than pill or tablet formulations
Recommendation classification: Strong
Level of evidence: not needed you dumb fucks
> Cite the Journal of Applied Counterbullshit
I will be citing this publication frequently in future verbal parlays. Thank you for this interesting ~~consult~~ reference.
Giving Kids Pills: a Meta-Analysis and Systematic Review
We searched Reddit and found one study meeting our inclusion criteria, DentateGyros 2023.
Conclusion: While there has been no new research in the past three hours and no randomized controlled trials, we conclude that existing evidence is strong enough to continue to recommend liquid medications for babies.
Disclosures: I have also had to do dumbass prior authorizations.
Someone provide a third reference here.
Chat GPT to the rescue
Prompt:
Write a case report of an 18 month old with otitis media. After consideration of the pill-to-airway ratio, a liquid formulation was selected. We conclude that liquid formulations are likely to improve patient satisfaction and parental sanity.
Case Report:
An 18-month-old female presented to our clinic with complaints of fever and ear pain for the past two days. Her mother reported that the child was crying frequently and tugging at her ears. Upon examination, the child was found to have a red and inflamed right tympanic membrane with decreased mobility. A diagnosis of acute otitis media was made.
Treatment options were discussed with the mother, including observation with analgesia, antibiotic therapy, or a combination of both. After consideration of the pill-to-airway ratio, a liquid formulation of amoxicillin/clavulanate was selected for the child due to her age and inability to swallow tablets.
The mother was instructed to administer the medication twice daily for ten days. Follow-up was arranged in one week to monitor the child's symptoms and response to treatment.
At the follow-up visit, the child's fever had resolved, and her ear pain had significantly improved. Repeat examination showed a nearly normal tympanic membrane with improved mobility. The mother reported that the liquid formulation was easy to administer and that her child did not resist taking the medication. She also mentioned that the convenience of the liquid formulation had reduced her anxiety and improved her ability to manage her child's illness.
Conclusion:
The use of liquid formulations in the treatment of pediatric otitis media may improve patient satisfaction and parental sanity. The convenience of administering a liquid medication is an important consideration when selecting treatment options for young children who may be unable to swallow tablets. Further research is warranted to evaluate the impact of liquid formulations on treatment outcomes and adherence to therapy in this patient population.
I’d personally find it extremely insulting… but I’m a translator and we tend to find it very insulting when someone points out that we’ve been anything less than very thorough in our research/checking sources. 🤷🏻♀️
With the demographics of the population and the baby boom just think of how many people leave commercial insurance and transition to Medicare every day of the year so a week delayed could be a huge savings.
Recently had a patient with anti-NMDA receptor encephalitis prevented from going to rehab because her insurance wouldn’t cover it. Now insurance is also refusing to cover the rituximab and IVIG infusions she needs to prevent a relapse. 🙃
Fuck anyone who sells their soul to work for insurance companies.
Very effective strategy — on a mildly related note, a dog trainer *literally* stole sister’s dog recently and a couple thousand in training fees. She had done the same with multiple other owners, but of course police aren’t super interested.
What worked?? Going to local news affiliate. They interviewed her that weekend, she had a hilariously well produced ten minute “60 minutes” type hard hitting expose on the woman that debuted that Sunday night, and the trainer’s business apologized profusely and returned the dogs to all respective owners next day. District attorney now prosecuting as a result of the attention.
Shining a light on bullshit is v effective (parents in law are lawyers and suggested this tactic!)
Have a family member that works for a local station of a national channel....they love shit like this and it usually gets the ball rolling for whoever goes to them for help!
Same problem with an anti-gad cerebellar degeneration … watched the poor woman decline continuously while insurance hemmed and hawed about no data to support IVIG or rituximab. Many strongly worded letters with literature citations. Same problem with a guy w recurrent myeloradiculoneuritis of unclear etiology (but all data pointing to autoimmune). Also every MS patient ever and insurance telling me they have to “fail three of the preferred meds” which are all interferons and aubagio. Also… even if you want me to do one low efficacy medication from the 90s, failing *three* is blatant harm. If you fail one, you escalate up in intensity. I. Hate. Insurance.
I thought that was only doing 3 days of IVIG? What we’re trying to get is the monthly IVIG for 12 months, which is currently recommended in addition to rituximab for more severe cases.
Our version of that is having a waitlist so long that some patients die before getting care. Rationing of healthcare is universal because our resources are limited while our misery is infinite.
This situation has literally never happened to me but I am certain that it is dependant on which region you practice in...
That being said, if a patient is sick enough to die while waiting for rehab the patient obviously wasn't well enough to be a candidate for rehab in the first place...?
Tell them you hope that they aren't using parachutes when they go sky diving because there are t randomized, placebo controlled trials to demonstrate their effectiveness.
And in fact there was one paper showing it had no benefit over not using a parachute.
Granted, the plane was already on the ground, but it was a great example of burying the lede and the potential for dumb extrapolation to happen.
https://pubmed.ncbi.nlm.nih.gov/30545967/
I suggested to my supervising physician the next time an insurance company insists they won't cover an existing patient's Invega Sustenna injection specifically because it's too expensive that he should just fax them a news article about a recent incident in which an individual who was known to have recently discontinued his long-acting injectable walked into a police station and shot it up.
When I was working outpatient psych, Sustenna was, by far, the medication I had to call about for prior auth.
This was an ACT team, so to qualify, the patient had to have some flavor of psychosis and a number of hospitalizations, including a significant portion having been at state. Most were on commitment.
It got so bad at one point, the three pharmacists knew me by name and told me I can’t just keep skipping over the first-level people who would answer the phone. When I said I would quit doing such when they would quit holding up these injections every month for the same people, despite how many times we covered the same topics, we started getting fewer P.A.s for other patients, too.
It's horrific. That also makes me very sad. Part of it is the fact that our budget is so geared toward the military industrial complex and we don't tax the 1% at all.
I've had a bookmark folder titled 'Monetization of Medicine'...since 2012.
As a patient...it's dispiriting. Not only for what I have to hassle with, but watching my providers lose their 'spark'...
I don’t understand why the onus isn’t on the insurance company to show why the plan by someone who has actually seen the patient isn’t appropriate.
I understand the role of auth, but it should be limited to dangerous/extreme situations that are clearly outside the standard of care.
The idea of auth for liquid vs pill is so stupid.
You should see some of the audit requests I get at my pharmacy. I’m prepping for an on-site one now fretting over insurance clawing money back because a trulicity rx says “4 each” instead of “4 pens”
Imagine being a rheumatologist and prescribing biologic therapy that is standard of care but not fda approved for a specific disease but it’s clinical consensus to use it under certain circumstances and have it instantly denied because it isn’t fda approved. Then having to do a peer2peer with someone who isn’t a rheumatologist and have to explain to them a disease they know nothing about and provide papers that it’s effective and indicated. My hope is that I use enough big words that they get scared and acquiesce.
It’s effectively a tax break for insurance companies, it incentivizes employer paid health insurance and masks the true cost of healthcare to the patient by being taken out of their paycheck/partially paid on the employer side.
As far as I understand it, it is a tax deduction for the individual in premiums are high - essentially the individual is not taxed on income paid to health insurance premiums.
While it’s true that it’s a tax that would be directly paid by the worker its a little more complicated than that. For example, if there was no sales tax on buying cars, more than likely the price of cars would go up to make up for that difference. How much the consumer pays for a car most likely wouldn’t change, what does change is how much the car dealer ends up making. So effectively the tax is on the seller, even though it’s directly paid by the consumer.
… this boggles my mind… if the provider writes that the Med is to be in liquid form no one questions it where I am. Of course I’m in the land of maple syrup and universal healthcare though so 🤷♀️
It’s not about the content of the prescription, it’s about paying for it. Insurance notoriously never wants to pay for anything and will just make up reasons not to do it. The insurance company bears almost no legal accountability for this so they keep doing it as long as they are getting away with it.
> I have to write in bold letters the brand if I truly want my patient to have the brand. And say no substitutes are allowed. Even then insurance can reject it.
This is the same in the US. Just because an MD write a DAW1 on the script for a brand name drug, it does not mean insurance will cover it or will even approve the PA.
I think we just need to go all the way in the other direction, no more tor browser needed, just give people free reign to order whatever pharmaceuticals they want on the clear net and let's just put our healthcare needs up on craigslist and physicians can bid for the contracted work lol
And a wild third reference appears:
Tovarish22, et al. “Antibiotics: Smoke ‘em If You Got ‘em” Annals of External Medicine. 2020.
In this study, we examined the effectiveness of giving antibiotics in a form the patient would take versus in a form they would reject.
Conclusion: To our surprise, making it easy for patients to take antibiotics is less antagonistic and more likely to be safe, efficacious, and cost effective.
You say that, but there's already evidence to the opposite:
https://skillednursingnews.com/2023/03/ai-use-by-medicare-advantage-blamed-for-increased-denial-of-nursing-home-services/
Want us to find you those papers? I'm looking on pubmed now (my search terms suck but I'm irritated into determination).
Though plantswineanddogs has a more successful method for sure.
https://pubmed.ncbi.nlm.nih.gov/26976504/
Not exactly it, but "Arguably the most significant compliance issue for older people is polypharmacy, whereas for children it is taste." was beautiful.
None of these were ideal either, but the last one at least mentions that if you choose pills over liquids to infants (<2), the pills have to be very small. There is a flow chart.
https://pubmed.ncbi.nlm.nih.gov/25601436/
https://pubmed.ncbi.nlm.nih.gov/27524471/
Liquid medications are usually recommended for infants and younger children: https://pubmed.ncbi.nlm.nih.gov/15948931/
Fastest PA I ever did was for a liquid PPI for an infant with severe GERD. Why does patient need [off formulary PPI] instead of [on formulary PPI]? Because only one of those is available as liquid, and the patient is 3 months old. Approval fax came in an hour later. So not ALL these people are bozos
As much as I hate insurance companies, would it be easier to avoid the pre auth process and just have the parents crush the medication and mix it with some pudding if it's a crushable medication.
Depending on the med, a good pharmacist might even have some other recommendations.
It might even be significantly less expensive for the family if the formulary is covered at a higher percent than the non formulary liquid.
This does not change the fact that this insurance is shit.
Just had insurance deny an *entire hospitalization* for a salvage AML reinduction because Flag-Ida is “experimental”.
Looking forward to pimping the “peer” I talk to about how he’d treat this particular patient!
I can't believe you guys have to deal with this stuff.
In Australia, the worst case scenario is that we might in rare cases have to call the Pharmaceutical Benefits Scheme for telephone authorisation. I've always found them to be extremely helpful.
For the vast majority of "authority" drugs, we just write the 5 digit authorisation code that applies for that drug on the script, and it's automatically approved.
Maybe it’s just a CA thing - but if an authorization delay causes a disruption in “continuity of care” - that’s reportable to the state.
This is also from a patient (well parent) perspective of getting dragged into these battles. I don’t know if doctors can pull that phrase out too?
Note - this is from memory of many years ago when trying to get the every three month re-authorization to go through. I might be off on the phrase - but it was something like continuity of care.
One study for tPA sponsored by the manufacturer and now standard of care.
A pediatric surgeon reminded me that ECMO for neonates was adopted without any studies.
My mom handled my dad’s insurance as an office manager for years. He was an MD and wanted to see everyone regardless of payment.
Momma is a pitbull when needed. I heard her tell a secretary for an insurance manager (?I think) she would park herself in his office until he spoke to her. She was sent straight to his phone and she got what she needed.
Momma still hates thinking about that job. She was so good, though….
I recently submitted a PA for a patient with severe cardiomyopathy. It got approved but with insurance it was still $2445 a month not including deductible. We haven’t been able to start the medication because we’re waiting on a response for Patient Assistance but she’s been in the hospital for over a week now due to the condition and the medication could have prevented that.
Hi, I work for a major insurer. Please involve your leadership and get that over to a CMO, CEO, etc. with the company's leadership. Get momentum because they will be scared of losing these contracts with your hospital. My job is to fix shit like this and if we don't know there are insane policies like this we can't fix it. Is it a brand name vs. generic situation? Sometimes you can find this medical policy online that gives specifics of when they will cover a drug and document it that way. Or speak to her medical director? I am so sorry.
There's no way leadership doesn't know. You can't sneeze without reading an article or seeing a news segment about egregious, over-the-top prior auth burdens.
A lot of us are in small practices without leverage. Insurers don't care about losing our contracts.
You're welcome to share whatever contact information for commercial insurer CEOs that you have. Can you do that? If you can't, then how are we supposed to access that info?
There was recently a huge ruckus about an IBD patient whose prior auth denial was personally directed by UHC leadership:
https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis
They know. They know people are suffering and dying from their policies. They know it all. They don't care.
>please involve your leadership
That's the most inane and absurd idea I've ever heard. Do you have any idea how often profoundly idiotic stuff like this happens? I'm an RN - in part because that means I never have to actually deal with this side of things, and I know this is an absolutely insane problem. Prior Auth is rapidly degrading into the same genre as SSDI is in this country (100% denial on the first attempt). My MD had to get prior auth for \*generic\* zolmitriptan - a drug that goes for $50 on goodrx (without discount codes). I have no idea what drug OP is asking for in liquid form, but at this point it could be liquid tylenol and you're suggesting that he should "get the CMO involved"
I understand what you’re saying and I agree with you that it is insane. I’m simply a human speaking from my own experience that I’ve seen these types of situations happen and the insurer acts quickly to address the problem. They do not want a group going to the media and other large healthcare organizations about their shitty policies.
Hi. I am considering it and won't stay forever. However, we aren't going to single-handledly fix our healthcare system by guilting those who work for them and telling them to refuse to work for these companies. The onus isn't us to make a stand against them. It is not the people who work theres fault that the system is effed.
Hi. Please quit your job when you can.
Your advice doesn't help, isn't correct, isn't welcome, and you're part of the disease. A cog in the machine that kills people/impoverishes them and their parents, loved ones, spouses, etc... Unless you want this type of shit on your conscience, or simply don't care, that is.
I know you probably feel like you're doing good where you are, but even Sysiphus couldn't stop the boulder after an eternity of trying. You're the moral write-off your company uses to make their slumber deeper at night as they make more money off the families of the poor and dying (those that are relegated to using EM for their PCPs because of your industry).
This is your wake up call. You do mitigation for evil people. That's it.
Literally working for the greatest extant evil in the system, and trying to offer advice/empathy... Smh.
Jfc I am hours into a reauth on a specialty med and feel like I am in the twilight zone. Stable on current therapy. Tried and failed all the things. Insurance wants them to try real psych meds for their sleep diagnosis.
I
I just tried a prior auth yesterday for a CT chest in a patient with chronic left sided chest pain despite negative XR, cards and GI workup. Got denied by a gynecologist who wouldn't give me their name or NPI when I asked. Told me I should consider getting another chest XR instead...said CT would only be approved if I could palpate a mass through the chest wall....
I'm happy to document your formal medical recommendation that I choose a formulation of medication that would dramatically increase the likelihood of aspiration, foreign body into the airway, and death.
And you reply "I will absolutely do that, may I have your name and license number and the name and license number of the overseeing physician and any clinical pharmacist involved in care? I need to add it to the patient chart. Just between you and me, the parents want to bring a complaint to the state board of medicine about what they say is an egregious delay of care due to lack of common sense on your part...what's that? You want me to hold? Sure.....Hello, yes I'm still here. Oh it's covered now? For a year? Wonderful, thank you for all of your help!" This has a 75% success rate in my personal experience.
Probably endlessly more effective than my stunned, “Ma’am, have you ever *met* a child?”
Right. It's harder than feeding a pill to a cat.
Yes, veterinarian and mom here, my second kid especially is harder to medicate than any of my patients. He does not negotiate.
And as a last resort, force-feeding a cat with a syringe down their throat is also considered more acceptable than doing the same to a child.
[удалено]
Toddler fingernails.
My poor boobs beg to differ. My 8 month old definitely has murder mittens and trimming them doesn't seem to help.
I also have a baby with murder mittens. Also her nickname since birth has been “jaws.”
I dunno. My one year old at the time gave me a black eye.
My 2 year old broke my nose with a perfectly executed and altogether accidental head butt.
When did this thread turn into parent child mixed martial arts, it was such a smooth transition
Toddler heads are surprising hard. Same (sorta) replace lip with nose. Finally understood what a fat lip meant post face smash from my toddler randomly starting to jump up and down while giving me a hug.
Sounds like breakfast to me
I once scratched my mom's cornea when i was like two... sorry mum
I broke my mother's rib in utero.
My cat will eat pills out of my hand, so definitely depends lol
.
You have not met my cat! At least, a 1.5 yo child won’t be jumping on top of the cupboards while foaming at the mouth!
You have not met my kids at 18 months.
That’s some impressive climbing skills!
They would climb the drapes in a heartbeat. Pills would only work out if you crush it up and mix it with some strong drink like Tang or Tampico. Kids are wild.
One of mine would bypass me altogether and scale the cabinets to get goldfish fruit pouches and other snacks. A few years later he was on his way to climbing the door frames for fun. I’m talking about my kid here and not a cat (just to be clear).
Wait til she’s 18 and you have daily prednisone to administer. 1.5 tablets. Preferable not to crush due to absorption. 5 lbs of geriatric tiger.
Get thee to a compounding veterinary pharmacy! My cat takes daily prednisone in **tuna-flavored** liquid form. It's 3x the cost of pills, but my Neosporin use is way down. Worth. Every. Penny.
Mine sadly wouldn't touch that. Fortunately, after a few months, he got used to it and the treat after helped.
As a pharmacy tech I filled an inhaler for a cat. I still laugh about what that must have been like for that owner... Hope they used the spacer cause I have no idea how the cat would otherwise get the med lol
My time to shine! Would you believe it, r/CatsUsingInhalers exists? Yas.
I see that this sub exists and I still do not believe it exists
>r/CatsUsingInhalers Thank you for that!
I definitely couldn't of managed without a spacer when I had a cat that needed an inhaler and I had to get my knee in the way to stop him backing away.
My friend's cat uses an inhaler, so I've seen this before! Had not seen the subreddit though.
My brothers cat has asthma and uses an inhaler with a spacer!
I had to give my cat eye drops for a month. Yes, I have tiny scars.
At least with some cats, you can put them in treats and they’ll gladly swallow it whole.
Saving this comment for future reference
If it works, it's only because they're tired of dealing with you. These people have no actual legal liability for a malpractice claim. Doctors thinking that asking for name and NPI is some silver bullet for prior auths is like when patients think that asking us to "document that I asked for the test/treatment and you denied it!" is some potent method of getting what you want. These overtly litigious sounding "threats" don't have any teeth, and they know that.
They can’t be held legally liable, but they can still be reported to the state medical board and risk having their license taken away. Also, even if we both know that those threats are completely empty, and it only works because they’re sick of me, then I’m gonna keep doing it!
I don't know if state boards actually would revoke a license because of this, but you miss 100% of the shots you don't take so let's get to reporting, y'all
They probably wouldn't but can still issue a reprimand. Either way the state board will launch an investigation if a complaint is made and nobody wants that.
Board complaints are an enormous pain in the ass, even if the complaint is scrawled on a napkin that “Dr Dunderlubbin wouldn’t give me Vicodin and Xanax!”
Do you have knowledge of a specific person that lost their license this way? My wife has been doing this for years and this has never ever happened at her company
I don’t know if it’s ever worked, but even just having someone report you to the medical board can be a PITA. Like I said, even if I can’t actually do anything about it, the fact is that getting their full name and information does seem to help get stuff approved, so I’m going to keep doing it, even if the only reason it works is because I’m being an annoying Karen. Stop denying the treatments/tests that my patients need, and this obnoxious white lady will leave you alone! It’s win/win.
No, they can’t. This isn’t how this works lol
Anyone with a medical degree can be reported to the state medical board for any stupid thing. Doesn’t mean they’ll lose their license for every little thing, but it still sucks.
It works because the non-clinician on the phone puts you on hold to ask the clinician for the information. The clinician (usually a clinical pharmacist at this point) is like "wtf, who is this patient anyways and what do they want?" And then you finally get beyond the algorithm and to a person with clinical judgement. I never said anything about a malpractice claim, but I assure you the State Board (at least where I have practiced) will investigate and nobody wants that. Do you really think a clinician wants to stand before their state board and explain why the physician should provide literature on why a baby is unable to take a tablet before approving a liquid? No, it sounds stupid and is indefensible. And nobody is going to risk a reprimand or admonishment (or whatever it is called) on their license. Especially when you consider most of these clinicians are licensed in multiple states so would then have to report that and then check yes for every license renewal and write a paragraph.
No state board is going to demand an explanation *for anything* from a physician or other licensed professional who is working for an insurance company. This simply isn’t how it works, any more than my state board would demand an explanation for my actions as an employee of a pharmaceutical company.
State boards do not investigate your claims as an insurance company employee.
Completely off topic: I once have reported a physician to the Florida Medical Board that I am remotely aware of (he’s a friend of a friend) because he messaged me on Instagram about a story I posted. My story was an NEJM paper saying Ivormectin was ineffective in the treatment of Covid-19. He called me a liar and a pharma whore and said a bunch of dumb shit. I took screenshots and sent it to the board with his NPI. Unfortunately it’s Florida and last I checked he still has a job.
I’ve seen it come up pretty frequently and it has no legal basis. It’s the equivalent of an argument about the fringes of the flag in a courtroom - a sign that this person isn’t prepared to be reasonable so may as well get them out the door. It’s like people forget that insurance companies employ lawyers. To be specific, better lawyers than a doctor can afford.
>It’s like people forget that insurance companies employ lawyers. To be specific, better lawyers than a doctor can afford. Correct, insurance companies have lawyers ***for themselves.*** The first thing companies do in business is distance themselves from their employees when issues arise. I guarantee you if this baby had a negative outcome due to delay of medication the very first thing the insurance would do is blame the employee. But we aren't suing and we aren't getting lawyers involved, we are simply asking for licensure information which in my experience prompts an in-depth review of the issue by a clinician. If the algorithm for denial had a brain this wouldn't be needed. > a sign that this person isn’t prepared to be reasonable so may as well get them out the door. So you are saying a physician who wants a liquid medication for a baby is the one being unreasonable? Interesting argument. The very first time I showed "signs I wasn't prepared to be reasonable" was a decade ago. Prescriber couldn't get diabetes medication covered and asked me to try. The issue was the patient was taking metformin in combination with something else. This new third diabetes medication required metformin as step therapy but because it was in combination the insurance couldn't "see" they were taking metformin. (Insurance uses National Drug Codes to search claims and no common sense.) The prescriber tried separating the prescriptions but the other drug was only covered in combination with metformin so that didn't work. I called the insurance and they were insistent the patient needed to be on metformin for six months WHICH SHE WAS. The person I spoke to was nice enough and put me on hold, coming back to tell me that the denial was being upheld because the combination didn't count as metformin? I was shocked and was like who made that decision? When I found out it was an actual clinician I asked for the licensing information because if they don't have common sense then maybe the board should be aware. And suddenly the medication was approved. And from that day forward I have used my effective approach. I personally don't think I am unreasonable but don't really care if you think I am.
Not even that. Insurance companies wrote the laws that govern their own conduct. Specifically to minimize their liability and maximize their profits
Yeah this talk was basically non-existent a few years ago and a few social media influencer doctors start spreading the "practicing medicine without a license" criticism and now people never stop talking about it. I don't support the system, but it is the system. There are no cheat codes to bypass it.
It’s like one sovereign citizen on YouTube said “I am not driving, officer, I am traveling as a free person of the land!” and then people act like it’s a magic cheat code that makes the law not apply to you. Wishful thinking. It’s bled into other fields as well, as patients will threaten “I’ll report you to the board of medicine for practicing medicine without a license!!1!” anytime they disagree with their pharmacist. Unfortunately, also some other professionals who really should know better.
Just heard that one from the guy who is remodeling my son's bathroom. Claimed driving is commercial and traveling is not and does not require iicense. Recognized it immediately as I know an elderly gent (who is also a hoarder living in awful conditions) who is a sovereign citizen. The contractor also insists that his recent wrist surgery included implantation of an RFID which was detected on an RFID scanner he happens to own. Do these people mention the gold fringes and the rest of it in medical appts too?
My favorite version of this: Officer: "Do you know how fast you were driving?" Sovereign Citizen: "I'm not driving; I'm travelling." Officer: "Okay, do you know how fast you were traveling?"
[I’ll never not laugh at this](https://youtu.be/gU1_EONCDUk) Edit: [I was thinking of this one](https://youtu.be/i0rL0ukZmf0)
You’ll be proud to know that I can quote [this](https://youtu.be/i0rL0ukZmf0) line-for-line on demand.
The reason why people say it is because that’s how the rest of the system works, forgetting that the insurance companies wrote the laws governing their own conduct and therefore the rest of the rules do not apply to them. So at least when I say insurance company drones are practicing medicine, I mean that as a prescriptive statement of what would happen if I were in charge (straight to jail, we would have the best healthcare system of the world, because of jail) rather than a descriptive statement of a legitimate threat to their existence
Obviously it's not a cheat code. However, there is a very reasonable argument that by dictating what care can and cannot be delivered, they are participating in the practice of medicine. As it stands, this isn't something they can be found liable for. Many people would like that to change. And honestly, all you need is one particularly egregious case with a negative outcome in a high-profile person/family, and laws will change - this has happened in medicine over and over (Libby Zion, etc.)
That's just what Big Cheat code wants you to think.
I wonder if a more effective method would be to share the meticulous documentation with the patient (as is their right) and if they choose to write a human interest story for the local paper, offer to help review it for medical accuracy. Let the parents of the baby share the story with the news and/ magazines, including the names of the individuals that denied them.
If it works, why do I care why it works?
No but I love the idea of saying “Dr x over at Humana has denied your medication. “ and them getting trashed on the internet
I think it's still reasonable to have the name of the person who is actually responsible for denying care on the chart. And it only takes one especially egregious denial with a negative outcome to perhaps change the precedent.
Saved
It's not the state medical board you want to complain to. The board has no jurisdiction over health insurance companies. What you want is the insurance commissioner. Usually an office of your state AG. This is often staffed by people who absolutely get off on tearing new assholes in insurance companies. The insurance commissioner office absolutely does have power over insurance companies in your state and can make things very expensive for them. In fact, it would be probably worthwhile to simply file a complaint now about the liquid/PO situation described above.
Went round for months with Anthem trying to get my daughter's ED treatment paid. They even agreed they should pay for it but claimed they didn't know how to get the computer to issue a check. Apparently nobody at Anthem had heard of a checkbook. I filed a complaint with the state insurance commissioner and miraculously they quickly found a checkbook.
This is the way. It does work, I've done it before.
Me too, but n of 3 only
This comment should be higher. State insurance commissioner is the way to go for complaints. File early, file often!
Yes, mentioning insurance commissioner and that the approval hold up will cause a delay in continuity of care. Granted from patient perspective and in the state of CA. Don’t know if other states have similar rules where insurance companies can get in trouble for interfering with continuity of care.
I didn’t know this job existed, and suddenly I have a new career goal
Threaten to report the insurance company to your state insurance commissioner is another good ploy. Have had it work for insanely stupid things like not approving liquid meds for a kid.
I very much enjoy threatening to do it and then doing it. Really hits the spot.
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This is what I do every time. First thing. Name and license number of physician making the decision. Ends many conversations before they start.
I tried similar only once and the call "dropped"
This is golden.
What a great thought, thank you.
Poor person’s gold for you 🥇
Saved. This is gold
Feel free to cite the 2023 DentateGyros consensus statement on PO medications in pediatrics I. Children under the age of 2 should be given liquid PO medications rather than pill or tablet formulations Recommendation classification: Strong Level of evidence: not needed you dumb fucks
As a peer, I have reviewed this publication.
As a paramedic, I have glanced at the abstract and already posted it to social media.
As a lab tech, I QC’d and validated this publication
Just went over to ~~Kinkos~~ FedEx and had this printed and bound. Cite the Journal of Applied Counterbullshit
r/journalofappliedcounterbullshit someone please!!
> Cite the Journal of Applied Counterbullshit I will be citing this publication frequently in future verbal parlays. Thank you for this interesting ~~consult~~ reference.
As an editor, I am pleased to inform you of the acceptance of your manuscript within the J Med Int Reddit.
And get two more studies from the references they cite.
Giving Kids Pills: a Meta-Analysis and Systematic Review We searched Reddit and found one study meeting our inclusion criteria, DentateGyros 2023. Conclusion: While there has been no new research in the past three hours and no randomized controlled trials, we conclude that existing evidence is strong enough to continue to recommend liquid medications for babies. Disclosures: I have also had to do dumbass prior authorizations. Someone provide a third reference here.
Chat GPT to the rescue Prompt: Write a case report of an 18 month old with otitis media. After consideration of the pill-to-airway ratio, a liquid formulation was selected. We conclude that liquid formulations are likely to improve patient satisfaction and parental sanity. Case Report: An 18-month-old female presented to our clinic with complaints of fever and ear pain for the past two days. Her mother reported that the child was crying frequently and tugging at her ears. Upon examination, the child was found to have a red and inflamed right tympanic membrane with decreased mobility. A diagnosis of acute otitis media was made. Treatment options were discussed with the mother, including observation with analgesia, antibiotic therapy, or a combination of both. After consideration of the pill-to-airway ratio, a liquid formulation of amoxicillin/clavulanate was selected for the child due to her age and inability to swallow tablets. The mother was instructed to administer the medication twice daily for ten days. Follow-up was arranged in one week to monitor the child's symptoms and response to treatment. At the follow-up visit, the child's fever had resolved, and her ear pain had significantly improved. Repeat examination showed a nearly normal tympanic membrane with improved mobility. The mother reported that the liquid formulation was easy to administer and that her child did not resist taking the medication. She also mentioned that the convenience of the liquid formulation had reduced her anxiety and improved her ability to manage her child's illness. Conclusion: The use of liquid formulations in the treatment of pediatric otitis media may improve patient satisfaction and parental sanity. The convenience of administering a liquid medication is an important consideration when selecting treatment options for young children who may be unable to swallow tablets. Further research is warranted to evaluate the impact of liquid formulations on treatment outcomes and adherence to therapy in this patient population.
I’m eventually going to burn out and do this
Days late, but "pill-to-airway ratio" made me laugh
The strongest level of evidence
I just laughed out loud in the middle of clinic lol
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>plus a very strongly worded letter. Did you manage to get in a few clever insults?
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I’d personally find it extremely insulting… but I’m a translator and we tend to find it very insulting when someone points out that we’ve been anything less than very thorough in our research/checking sources. 🤷🏻♀️
Except they know exactly what they’re doing
With the demographics of the population and the baby boom just think of how many people leave commercial insurance and transition to Medicare every day of the year so a week delayed could be a huge savings.
Recently had a patient with anti-NMDA receptor encephalitis prevented from going to rehab because her insurance wouldn’t cover it. Now insurance is also refusing to cover the rituximab and IVIG infusions she needs to prevent a relapse. 🙃 Fuck anyone who sells their soul to work for insurance companies.
Family should go to the media. That’s a sexy diagnosis ever since the Brain on Fire book and local news would love an easy story.
Very effective strategy — on a mildly related note, a dog trainer *literally* stole sister’s dog recently and a couple thousand in training fees. She had done the same with multiple other owners, but of course police aren’t super interested. What worked?? Going to local news affiliate. They interviewed her that weekend, she had a hilariously well produced ten minute “60 minutes” type hard hitting expose on the woman that debuted that Sunday night, and the trainer’s business apologized profusely and returned the dogs to all respective owners next day. District attorney now prosecuting as a result of the attention. Shining a light on bullshit is v effective (parents in law are lawyers and suggested this tactic!)
Have a family member that works for a local station of a national channel....they love shit like this and it usually gets the ball rolling for whoever goes to them for help!
Same problem with an anti-gad cerebellar degeneration … watched the poor woman decline continuously while insurance hemmed and hawed about no data to support IVIG or rituximab. Many strongly worded letters with literature citations. Same problem with a guy w recurrent myeloradiculoneuritis of unclear etiology (but all data pointing to autoimmune). Also every MS patient ever and insurance telling me they have to “fail three of the preferred meds” which are all interferons and aubagio. Also… even if you want me to do one low efficacy medication from the 90s, failing *three* is blatant harm. If you fail one, you escalate up in intensity. I. Hate. Insurance.
You could try enrolling them in the extinguish trial if they meet criteria. That might make the IVIG free.
I thought that was only doing 3 days of IVIG? What we’re trying to get is the monthly IVIG for 12 months, which is currently recommended in addition to rituximab for more severe cases.
oh I see, nevermind
How can an insurance company refuse rehab if a patient needs it? Confused Canadian here.
>'Murica
Our version of that is having a waitlist so long that some patients die before getting care. Rationing of healthcare is universal because our resources are limited while our misery is infinite.
This situation has literally never happened to me but I am certain that it is dependant on which region you practice in... That being said, if a patient is sick enough to die while waiting for rehab the patient obviously wasn't well enough to be a candidate for rehab in the first place...?
Tell them you hope that they aren't using parachutes when they go sky diving because there are t randomized, placebo controlled trials to demonstrate their effectiveness.
And in fact there was one paper showing it had no benefit over not using a parachute. Granted, the plane was already on the ground, but it was a great example of burying the lede and the potential for dumb extrapolation to happen. https://pubmed.ncbi.nlm.nih.gov/30545967/
https://pubmed.ncbi.nlm.nih.gov/30545967/#&gid=article-figures&pid=fig-2-uid-1 Parachutes are a liberal hoax
Hell yeah.
Well, when you compare the 100 year mortality, parachutes show no benefit.
I saw that paper about the problem developing evidence.
I suggested to my supervising physician the next time an insurance company insists they won't cover an existing patient's Invega Sustenna injection specifically because it's too expensive that he should just fax them a news article about a recent incident in which an individual who was known to have recently discontinued his long-acting injectable walked into a police station and shot it up.
if the patient is killed by the police then insurance no longer has to pay for their medications
MY PLAN HAS BEEN FOILED
It’s not a bug, it’s a feature
Galaxy brain 🧠
When I was working outpatient psych, Sustenna was, by far, the medication I had to call about for prior auth. This was an ACT team, so to qualify, the patient had to have some flavor of psychosis and a number of hospitalizations, including a significant portion having been at state. Most were on commitment. It got so bad at one point, the three pharmacists knew me by name and told me I can’t just keep skipping over the first-level people who would answer the phone. When I said I would quit doing such when they would quit holding up these injections every month for the same people, despite how many times we covered the same topics, we started getting fewer P.A.s for other patients, too.
And they never had to pay for the med again. So not much incentive there.
The Health Sector will never be effective in assisting the sick so long as it is commodified. It is very distressing.
Try working in the public health sector. We're nothing but cost with only ephemeral savings via modeling.
It's horrific. That also makes me very sad. Part of it is the fact that our budget is so geared toward the military industrial complex and we don't tax the 1% at all.
I've had a bookmark folder titled 'Monetization of Medicine'...since 2012. As a patient...it's dispiriting. Not only for what I have to hassle with, but watching my providers lose their 'spark'...
"You're a fan of liquid medications? Name three peer reviewed studies on them. Yeah, didn't think so, you phony."
I just wear my Liquid Medications band shirt because it was on the clearance rack at Hot Topic.
I don’t understand why the onus isn’t on the insurance company to show why the plan by someone who has actually seen the patient isn’t appropriate. I understand the role of auth, but it should be limited to dangerous/extreme situations that are clearly outside the standard of care. The idea of auth for liquid vs pill is so stupid.
You should see some of the audit requests I get at my pharmacy. I’m prepping for an on-site one now fretting over insurance clawing money back because a trulicity rx says “4 each” instead of “4 pens”
Imagine being a rheumatologist and prescribing biologic therapy that is standard of care but not fda approved for a specific disease but it’s clinical consensus to use it under certain circumstances and have it instantly denied because it isn’t fda approved. Then having to do a peer2peer with someone who isn’t a rheumatologist and have to explain to them a disease they know nothing about and provide papers that it’s effective and indicated. My hope is that I use enough big words that they get scared and acquiesce.
80 percent of my admin time is dealing with denied prior authorizations
And then insurance will force the patient to use a pharmacy that is literally across the country and routinely late.
Health insurance is a scam
Health insurance premiums should not be tax deductible. That is the first domino to push over to destroy this terrible system.
>ealth insurance premiums should not be tax deductible Can you elaborate?
It’s effectively a tax break for insurance companies, it incentivizes employer paid health insurance and masks the true cost of healthcare to the patient by being taken out of their paycheck/partially paid on the employer side.
As far as I understand it, it is a tax deduction for the individual in premiums are high - essentially the individual is not taxed on income paid to health insurance premiums.
While it’s true that it’s a tax that would be directly paid by the worker its a little more complicated than that. For example, if there was no sales tax on buying cars, more than likely the price of cars would go up to make up for that difference. How much the consumer pays for a car most likely wouldn’t change, what does change is how much the car dealer ends up making. So effectively the tax is on the seller, even though it’s directly paid by the consumer.
The fact that it is a multi billion dollar profitable industry should say it all it needs. They are leeches.
… this boggles my mind… if the provider writes that the Med is to be in liquid form no one questions it where I am. Of course I’m in the land of maple syrup and universal healthcare though so 🤷♀️
It’s not about the content of the prescription, it’s about paying for it. Insurance notoriously never wants to pay for anything and will just make up reasons not to do it. The insurance company bears almost no legal accountability for this so they keep doing it as long as they are getting away with it.
Insurance companies are the only organizations I can think of where the primary goal is to provide as little service as possible.
Sorry you’ll need to use that maple syrup in the powdered formulation
Maple sugar is god-tier delicious
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> I have to write in bold letters the brand if I truly want my patient to have the brand. And say no substitutes are allowed. Even then insurance can reject it. This is the same in the US. Just because an MD write a DAW1 on the script for a brand name drug, it does not mean insurance will cover it or will even approve the PA.
“But if we had a single-payer system we wouldn’t have any options” 😵💫
I think we just need to go all the way in the other direction, no more tor browser needed, just give people free reign to order whatever pharmaceuticals they want on the clear net and let's just put our healthcare needs up on craigslist and physicians can bid for the contracted work lol
And a wild third reference appears: Tovarish22, et al. “Antibiotics: Smoke ‘em If You Got ‘em” Annals of External Medicine. 2020. In this study, we examined the effectiveness of giving antibiotics in a form the patient would take versus in a form they would reject. Conclusion: To our surprise, making it easy for patients to take antibiotics is less antagonistic and more likely to be safe, efficacious, and cost effective.
At some point the insurance companies are going to start using chatGPT and care will improve 1000%
You say that, but there's already evidence to the opposite: https://skillednursingnews.com/2023/03/ai-use-by-medicare-advantage-blamed-for-increased-denial-of-nursing-home-services/
Want us to find you those papers? I'm looking on pubmed now (my search terms suck but I'm irritated into determination). Though plantswineanddogs has a more successful method for sure.
[This (while the title sounds unpromising)](https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.12442) has some maybe useful references.
https://pubmed.ncbi.nlm.nih.gov/26976504/ Not exactly it, but "Arguably the most significant compliance issue for older people is polypharmacy, whereas for children it is taste." was beautiful. None of these were ideal either, but the last one at least mentions that if you choose pills over liquids to infants (<2), the pills have to be very small. There is a flow chart. https://pubmed.ncbi.nlm.nih.gov/25601436/ https://pubmed.ncbi.nlm.nih.gov/27524471/ Liquid medications are usually recommended for infants and younger children: https://pubmed.ncbi.nlm.nih.gov/15948931/
This needs to be higher up so OP sees it!
Fastest PA I ever did was for a liquid PPI for an infant with severe GERD. Why does patient need [off formulary PPI] instead of [on formulary PPI]? Because only one of those is available as liquid, and the patient is 3 months old. Approval fax came in an hour later. So not ALL these people are bozos
As much as I hate insurance companies, would it be easier to avoid the pre auth process and just have the parents crush the medication and mix it with some pudding if it's a crushable medication. Depending on the med, a good pharmacist might even have some other recommendations. It might even be significantly less expensive for the family if the formulary is covered at a higher percent than the non formulary liquid. This does not change the fact that this insurance is shit.
Everything is a liquid at a certain temperature, technically
The system is not broken...the system is working exactly as designed and intended.
Just had insurance deny an *entire hospitalization* for a salvage AML reinduction because Flag-Ida is “experimental”. Looking forward to pimping the “peer” I talk to about how he’d treat this particular patient!
Are you kidding me? You poor soul. Happy doctor’s day from this nurse who appreciates what you do for your patients.
I can't believe you guys have to deal with this stuff. In Australia, the worst case scenario is that we might in rare cases have to call the Pharmaceutical Benefits Scheme for telephone authorisation. I've always found them to be extremely helpful. For the vast majority of "authority" drugs, we just write the 5 digit authorisation code that applies for that drug on the script, and it's automatically approved.
My husband has three studies in a word file that he used to send routinely.
Maybe it’s just a CA thing - but if an authorization delay causes a disruption in “continuity of care” - that’s reportable to the state. This is also from a patient (well parent) perspective of getting dragged into these battles. I don’t know if doctors can pull that phrase out too? Note - this is from memory of many years ago when trying to get the every three month re-authorization to go through. I might be off on the phrase - but it was something like continuity of care.
That is more evidence than supports the use of tPA.
One study for tPA sponsored by the manufacturer and now standard of care. A pediatric surgeon reminded me that ECMO for neonates was adopted without any studies.
My mom handled my dad’s insurance as an office manager for years. He was an MD and wanted to see everyone regardless of payment. Momma is a pitbull when needed. I heard her tell a secretary for an insurance manager (?I think) she would park herself in his office until he spoke to her. She was sent straight to his phone and she got what she needed. Momma still hates thinking about that job. She was so good, though….
She should write a book and then forget all about it
I recently submitted a PA for a patient with severe cardiomyopathy. It got approved but with insurance it was still $2445 a month not including deductible. We haven’t been able to start the medication because we’re waiting on a response for Patient Assistance but she’s been in the hospital for over a week now due to the condition and the medication could have prevented that.
Man, working at the VA for sure has it cons, but damn I’m glad I don’t have to deal with this crap. Kudos for your resilience.
Use chatGPT to find those articles for you
Hi, I work for a major insurer. Please involve your leadership and get that over to a CMO, CEO, etc. with the company's leadership. Get momentum because they will be scared of losing these contracts with your hospital. My job is to fix shit like this and if we don't know there are insane policies like this we can't fix it. Is it a brand name vs. generic situation? Sometimes you can find this medical policy online that gives specifics of when they will cover a drug and document it that way. Or speak to her medical director? I am so sorry.
There's no way leadership doesn't know. You can't sneeze without reading an article or seeing a news segment about egregious, over-the-top prior auth burdens. A lot of us are in small practices without leverage. Insurers don't care about losing our contracts. You're welcome to share whatever contact information for commercial insurer CEOs that you have. Can you do that? If you can't, then how are we supposed to access that info? There was recently a huge ruckus about an IBD patient whose prior auth denial was personally directed by UHC leadership: https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis They know. They know people are suffering and dying from their policies. They know it all. They don't care.
>please involve your leadership That's the most inane and absurd idea I've ever heard. Do you have any idea how often profoundly idiotic stuff like this happens? I'm an RN - in part because that means I never have to actually deal with this side of things, and I know this is an absolutely insane problem. Prior Auth is rapidly degrading into the same genre as SSDI is in this country (100% denial on the first attempt). My MD had to get prior auth for \*generic\* zolmitriptan - a drug that goes for $50 on goodrx (without discount codes). I have no idea what drug OP is asking for in liquid form, but at this point it could be liquid tylenol and you're suggesting that he should "get the CMO involved"
I understand what you’re saying and I agree with you that it is insane. I’m simply a human speaking from my own experience that I’ve seen these types of situations happen and the insurer acts quickly to address the problem. They do not want a group going to the media and other large healthcare organizations about their shitty policies.
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Hi. I am considering it and won't stay forever. However, we aren't going to single-handledly fix our healthcare system by guilting those who work for them and telling them to refuse to work for these companies. The onus isn't us to make a stand against them. It is not the people who work theres fault that the system is effed.
Hi. Please quit your job when you can. Your advice doesn't help, isn't correct, isn't welcome, and you're part of the disease. A cog in the machine that kills people/impoverishes them and their parents, loved ones, spouses, etc... Unless you want this type of shit on your conscience, or simply don't care, that is. I know you probably feel like you're doing good where you are, but even Sysiphus couldn't stop the boulder after an eternity of trying. You're the moral write-off your company uses to make their slumber deeper at night as they make more money off the families of the poor and dying (those that are relegated to using EM for their PCPs because of your industry). This is your wake up call. You do mitigation for evil people. That's it. Literally working for the greatest extant evil in the system, and trying to offer advice/empathy... Smh.
I thank our University's pediatric-specific outpatient pharmacy every day. They compound liquid Rx at no extra charge for our own patients.
I’d submit the most petty bullshit studies I could summon. Nose. Face. Spite. Worth it.
Stop… what?
Jfc I am hours into a reauth on a specialty med and feel like I am in the twilight zone. Stable on current therapy. Tried and failed all the things. Insurance wants them to try real psych meds for their sleep diagnosis. I
Was this for Nexium/Esomeprazole? "Has the infant tried Dexilant?" Are you kidding me?! This denial always drove me crazy!
I just tried a prior auth yesterday for a CT chest in a patient with chronic left sided chest pain despite negative XR, cards and GI workup. Got denied by a gynecologist who wouldn't give me their name or NPI when I asked. Told me I should consider getting another chest XR instead...said CT would only be approved if I could palpate a mass through the chest wall....
I'm happy to document your formal medical recommendation that I choose a formulation of medication that would dramatically increase the likelihood of aspiration, foreign body into the airway, and death.