Dear 3rd party player! I’ve had it, and I’m not taking it sitting down anymore! Appeal this!

This morning I operated on my patients; this afternoon I’m fighting the denials from their insurance companies for their care. I am exasperated, but when the patients and I just get fed up and give in (the patient just pays for it or the physician writes off the bill), the insurance companies win, profit, and redouble their efforts. I am looking forward to 10/01/2015 when I am liberated from this government-run, third party-controlled healthcare mess and practice under a new alternate model where my patients and I freely engage in a patient-doctor relationship, and I serve them first to the best of my ability with state of the art care, compassion, confidentiality , and dignity for a fair, reasonable, transparent fee. Until then, I’m not giving up the fight. The companies are ripping patients off- huge premiums, huge deductibles, huge co-pays- and for what? Delays, denials, narrow networks, and restriction of care. Here is today’s letter to a company denying coverage for a drug that works beautifully for my patient. I bet I’ll hear nothing back. Typically we’re stonewalled- the patients and doctors nothing but an annoying inconvenience in the big government/big business $3T dollar a year healthcare bonanza.

Dear third party entity that is denying coverage for a prescription drug I have written for my patient,

In the current healthcare environment, government mandates that patients buy health insurance from insurance companies such as yours that have subsequently developed and implemented major strategies which primarily delay and deny care to these patients but secondarily increase your bottom line. The three most common delay tactics for medications are 1.) requiring preauthorization, 2.) establishing quantity limits, and 3.) requiring step edits. These tactics are harmful to patients and waste incredible resources such as the time I have spent talking to my patient and staff about this and now writing to you. I could have been caring for other patients at this time when physician shortages are resulting in limited access to care, and physicians are living a bureaucratic nightmare.

When my patients seek my care, I thoroughly evaluate, diagnose, and treat them. When indicated, I write a prescription for a medication that will alleviate their symptoms or cure their condition. I write the prescription, because I want them to be treated with that particular drug. When possible I will authorize that a generic may be dispensed if adequately safe and efficacious. A prescription I write for my patient is not a request for you to pontificate. You are interfering in the patient-doctor relationship and effectively practicing medicine without a license. You are causing increased suffering, morbidity, and potential mortality for patients whose care you are delaying and denying.

In this particular case, you have denied filling the prescription for Restasis I wrote for a patient who has a long history of severe dry eyes dating back to March 10, 2003, when I became her physician more than twelve years ago. Her condition is well documented in her confidential medical record and supported by ancillary testing, as is her excellent response both symptomatically and clinically to her use of Restasis for the past few years.

I received a “prior authorization request denial” stating the information submitted does not indicate a trial of the formulary alternative: steroid eye drops. I am stunned on many levels. A steroid alternative is not an appropriate or equivalent alternative for Restasis. Steroid eye drops can cause cataracts and glaucoma, which Restasis does not. Steroids and Restasis are not even in the same class of drugs. Will your company bear the blame when a new generation of patients presents with iatrogenic premature cataracts and glaucoma which will then require increased expense treating those conditions and in some cases will result in permanent visual loss?

Someone must advocate for the patients. It is ethically wrong that your company is choosing to act not as a provider of health insurance but as a provider of health care, for which you are not qualified. Worse is that in this perverse system your clients are forced to buy what you promise to provide, and you profit by denying them what you promised to provide. No longer will I play this game nor allow you to take advantage of my patients in this deplorable fashion.

Your letter states: “If you wish to file an appeal please contact PARx Solutions at 866-725-7279 to review the appeals process.” My response to you is: 1.)fill the prescription I wrote which is indicated for my patient who pays you to provide access to care not to delay and deny it, and 2.) do not tell me to use an alternative therapy that is wrong and potentially harmful, if not blinding, to my patient. That is my appeal. I will copy my patient on this letter, and I expect you to honor your commitment to her by covering the prescription I wrote.


Kristin S. Held, MD


3 thoughts on “Dear 3rd party player! I’ve had it, and I’m not taking it sitting down anymore! Appeal this!

  1. The only way to fix this system is to LEAVE IT and offer a payment system that is affordable to the patient. “Health” Insurance is broken beyond repair. It must burn to the ground and we must create another system which does not involve government or a third party payer. It sounds scary but that is what we have done in our office and it works.

  2. Pingback: Dear 3rd party player! I’ve had it, and I’m not taking it sitting down anymore! Appeal this! | bchosen

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