Prior Authorization Physician Response Letter

I’ve had it with insurance companies and their efforts to delay and deny my patient’s care. Here is a letter I will be sending in response when my patient is hit with the dreaded but expected “Prior Authorization” requirement instead of having the prescription I wrote for them rightfully filled. (Note: I chose $46.00 because Hippocrates was born in 460 B.C., and it is an annoying amount for which the usurious intermediary company will have to keep accounting. That is also why I request they respond by Fax- the annoyance factor. They taught me well.) We can’t take this sitting down any longer. We must stand for our patients.

 

Kristin S. Held, M.D.

 

Physician Consult Request for Prior Authorization Information Research, Experimentation, and Transmittal

Dear Pharmacy Drug Benefit Manager,

Thank you for your physician consult request for prior authorization of my patient’s medication and, when indicated, your request that I alter my patient’s treatment plan to experiment with a different drug that you and the insurance company, with whom you have a contractual relationship, prefer based on economic considerations which benefit you and the insurance company the most, overriding the best interest of my patient. Please note that I have no contractual agreement with you or the insurance company with whom you and the patient are contractually bound, while the insurance company is contractually bound to its client, my patient. However, I am bound to my patient (the insurance company’s client) by a far stronger bond, the existence of a valid patient-physician relationship and the Hippocratic Oath, which I hold most deeply. I serve my patient first.

Should my patient willingly agree to the trial of a different drug which is the most economical for the insurance provider versus the prescribed medication which has proven to control the patient’s condition, I will agree to navigate my patient safely through this process as long as I believe it is not harmful for my patient to participate in this study. This drug trial is undertaken solely because of your delay or denial to fill the valid prescription I wrote for my patient, not because it is beneficial for the health and well-being of my patient. The study will terminate should my patient experience any untoward effects.

Because this study is being undertaken for the financial benefit of you and the insurance company with whom you work, you and the insurance company shall bear the monetary cost of such study including cost of your proposed study drug, cost of patient’s follow up examinations to prove your proposed drug is effective, safe, and free of side effects,  and expense reimbursement to patient for lost wages, missed work, child care, transportation, and other such expenses incurred as a result of your requiring the patient to undergo this drug trial.

Additionally, to review the patient medical record and complete your Prior Authorization form, please help my administrative staff provide better care to your client by helping lift some of the nonclinical administrative burdens that can and should be performed by administrative staff trained for such work, instead of taking the physicians and providers away from the exam room and operating room doing what they are trained to do.

If you still feel you need the physician expertise to assist you in performing this therapeutic drug trial and assist you in performing your managerial data gathering duties associated with your prior authorization requirements, please remit $46.00 payable to Kristin Story Held, MD to help defray the costs involved with your request.

Please fill out the form below so we can either,

  • Prepare your request in a timely fashion or make arrangements for the patient to begin the trial of your economically preferred drug in a safe and expeditious fashion or 2) know that you have taken your responsibility for your job and let us get on with ours.

Name of Pharmacy Drug Benefit Management Entity

___________________________________________________________ Date _________________

 

______ We will need the expertise of a physician or clinical provider to perform our managerial duties required for prior authorization and when indicated arrange for the patient to participate in a trial of our economically preferred drug and have enclosed $46.00 check payable to Kristin Story Held, M.D. Please send to address below. Prior Authorization will be completed upon receipt of funds.

______ We agree to reimburse the patient for all costs incurred related to trying the drug we prefer in lieu of the drug the physician has prescribed. We will pay for the cost of our preferred drug.

______ We will use our own resources and staff to perform our managerial duties and will not need the expertise of a physician to gather the needed data, and we authorize coverage for the drug which the physician has prescribed for the patient. (Please fax to 210-490-6759)

We look forward to partnering with you to help provide our patients (your clients) with exceptional yet cost effective care.

Kristin Story Held, M.D.

I got the gumption to do this at an AAPS (Association of American Physicians and Surgeons) meeting from a talk by  Internist Gregory P. Zydiak, M.D. He sends a letter accompanied by the following case. You can watch his talk online at http://www.aapsonline.org Here is a link to a court case that establishes precedence/ supports the physician in such cases:

https://www.acpinternist.org/weekly/archives/2008/3/18/court_decision.pdf

 

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7 thoughts on “Prior Authorization Physician Response Letter

  1. But do you also send them a copy of the judgement against the insurance company which gives precedent? You should.

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