Re: Actual prior auth call

[Guest guest]

I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back :)My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more.

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: I give all the informationOperator#1: Great, what can I do for you today?Me: I need a prior auth done for Januvia.Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.Me: Great.Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: Ok, and I give all the information over again.Operator #2: What can I do for you today?Me: I would like to complete a prior auth for Januvia.Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?Me: No, I would rather do it over the phone.Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?Me: No. He got severe diarrhea from the metformin.Operator#2: Did the patient have elevated liver function tests on metformin?Me: No. He got severe diarrhea on the metformin.Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.Operator#2: I’m sorry, you have to answer yes or no.Me: Well, I guess the answer would be “no†as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.Operator#2: I’m sorry sir, would you like to talk to the pharmacist?Me: Please.Operator#2: Thanks for your patience, the pharmacist is now on the line.Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.Pharmacist: I’m sorry, I need a yes or no answer.Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?Pharmacist: I’m sorry, I can’t help you answer the question.Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.Me: Then the answer to the last question is yes.Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.Operator #2: Is there anything else we can help you with today? No? Ok. This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

[Guest guest]

And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly...

I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format....

To: " " < >Sent: Wed, April 20, 2011 10:52:49 PMSubject: Re: Actual prior auth call

I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back

My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more.

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no†as he can still take sulfonylureas.

Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.

Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

[Guest guest]

,Yep. I am coming up on my 8th anniversary of opening next week, and the number of prior auths for meds, radiological procedures and even labs (if you consider they all must have the appropriate ICD codes attached) has skyrocketed. The sad part is that none of this added time is reimbursed, so not only is there the frustration of the insanity, but there is the shift of administrative costs from the insurer to the pharmaceutical supply company and ultimately to us. We lose money simply because we are trying to help out our patient. Of course, the increased administrative cost also changes our behaviors, which potentially affects our clinical decision making. Yet no one sues the insurance company or the pharmacy distributer for missing something or for not achieving optimal control.Of course, then we have a whole bunch of people trying to figure out why 60% of primary care docs would leave tomorrow if they could. From: [mailto: ] On Behalf Of PrattSent: Wednesday, April 20, 2011 10:53 PMTo: Subject: Re: Actual prior auth call I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back :)My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: I give all the informationOperator#1: Great, what can I do for you today?Me: I need a prior auth done for Januvia.Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.Me: Great.Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: Ok, and I give all the information over again.Operator #2: What can I do for you today?Me: I would like to complete a prior auth for Januvia.Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?Me: No, I would rather do it over the phone.Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?Me: No. He got severe diarrhea from the metformin.Operator#2: Did the patient have elevated liver function tests on metformin?Me: No. He got severe diarrhea on the metformin.Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.Operator#2: I’m sorry, you have to answer yes or no.Me: Well, I guess the answer would be “no†as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.Operator#2: I’m sorry sir, would you like to talk to the pharmacist?Me: Please.Operator#2: Thanks for your patience, the pharmacist is now on the line.Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.Pharmacist: I’m sorry, I need a yes or no answer.Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?Pharmacist: I’m sorry, I can’t help you answer the question.Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.Me: Then the answer to the last question is yes.Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.Operator #2: Is there anything else we can help you with today? No? Ok. This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

[Guest guest]

,Here is the problem with the fax. It totally eliminates any contact with the patient or the patient advocate. Why would an administrator anywhere give your patient the benefit of the doubt and allow a medication request to go through if they a) never have to meet the person and never have to even talk to that person or his angry doctor. It’s kind of like when people write ugly e-mails—as long as it is shrouded in the technology world and they are not actually talking to the person, then people say really evil and hateful things. They do it because they have a total disconnect from the actual person (full of emotions and in this case medical problems). Adding the fax only adds another barrier to overcome. From: [mailto: ] On Behalf Of BleiweissSent: Wednesday, April 20, 2011 11:36 PMTo: Subject: Re: Actual prior auth call And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly... I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format.... To: " " < >Sent: Wed, April 20, 2011 10:52:49 PMSubject: Re: Actual prior auth call I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back :)My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: I give all the informationOperator#1: Great, what can I do for you today?Me: I need a prior auth done for Januvia.Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.Me: Great.Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: Ok, and I give all the information over again.Operator #2: What can I do for you today?Me: I would like to complete a prior auth for Januvia.Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?Me: No, I would rather do it over the phone.Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?Me: No. He got severe diarrhea from the metformin.Operator#2: Did the patient have elevated liver function tests on metformin?Me: No. He got severe diarrhea on the metformin.Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.Operator#2: I’m sorry, you have to answer yes or no.Me: Well, I guess the answer would be “no†as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.Operator#2: I’m sorry sir, would you like to talk to the pharmacist?Me: Please.Operator#2: Thanks for your patience, the pharmacist is now on the line.Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.Pharmacist: I’m sorry, I need a yes or no answer.Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?Pharmacist: I’m sorry, I can’t help you answer the question.Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.Me: Then the answer to the last question is yes.Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.Operator #2: Is there anything else we can help you with today? No? Ok. This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

[Guest guest]

,Patients just don't get what goes on behind the scenes. But your anecdote makes it real and poignantly funny. You have a great ear for dialog. You should write this up for an op ed piece. I suspect the reasons for this disruptive interference resulting from the 'Prior Authorization Game' are:1. Delay paying for services. Insurance companies make their real money on the float time interval between receiving premiums to pay out for services. Even a day, or part of a day makes a difference to them. 2. Convince patients and doctors that the insurance company is needed for healthcare. The rock bottom reality is that there are only two basic benefits that health insurance provides to society:1. Access to capital markets. That is, a large company can move money around by collecting it then diverting it in various directions. Only some of that money goes to pay for heath care. Health insurance is really just a method of processing credit to 'pay' for healthcare, like a Visa credit card. 2. Jobs. The insurance industry provides lots of jobs. It takes a large number of people to run a credit processing industry. Jobs are good. An unintentional side benefit occurred early on when HMOs began limiting the length of hospital stays resulting in savings. However, since plucking that low hanging fruit, there is likely not much more to be wrung from health care. Further, any savings from manipulating health care practices do not accrue to the patients; the savings add to the right side of the balance sheets of the insurance corporations. How we got into this mess is history, but still makes no sense currently in the actual care of patients. Thinking in a glass half full mode, there is a potential benefit to society from the insurance industry's ability to disseminate information. Currently the reality is that this power to spend money on health education, is mostly dissipated in marketing the companies themselves.Kathleen (Dr. Grumpy in Beantown),Here is the problem with the fax. It totally eliminates any contact with the patient or the patient advocate. Why would an administrator anywhere give your patient the benefit of the doubt and allow a medication request to go through if they a) never have to meet the person and never have to even talk to that person or his angry doctor. It’s kind of like when people write ugly e-mails—as long as it is shrouded in the technology world and they are not actually talking to the person, then people say really evil and hateful things. They do it because they have a total disconnect from the actual person (full of emotions and in this case medical problems). Adding the fax only adds another barrier to overcome. From: [mailto: ] On Behalf Of BleiweissSent: Wednesday, April 20, 2011 11:36 PMTo: Subject: Re: Actual prior auth call And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly... I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format.... To: " " < >Sent: Wed, April 20, 2011 10:52:49 PMSubject: Re: Actual prior auth call I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back :)My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: I give all the informationOperator#1: Great, what can I do for you today?Me: I need a prior auth done for Januvia.Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.Me: Great.Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?Me: Ok, and I give all the information over again.Operator #2: What can I do for you today?Me: I would like to complete a prior auth for Januvia.Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?Me: No, I would rather do it over the phone.Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?Me: No. He got severe diarrhea from the metformin.Operator#2: Did the patient have elevated liver function tests on metformin?Me: No. He got severe diarrhea on the metformin.Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.Operator#2: I’m sorry, you have to answer yes or no.Me: Well, I guess the answer would be “no” as he can still take sulfonylureas.Operator#2: Then the medication cannot be approved.Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.Operator#2: I’m sorry sir, would you like to talk to the pharmacist?Me: Please.Operator#2: Thanks for your patience, the pharmacist is now on the line.Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.Pharmacist: I’m sorry, I need a yes or no answer.Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.Me: Would you consider a treatment failure a contraindication?Pharmacist: I’m sorry, I can’t help you answer the question.Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.Me: Then the answer to the last question is yes.Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.Operator #2: Is there anything else we can help you with today? No? Ok. This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

[Guest guest]

So what's the consensus among IMPs on how to handle this stuff? It can

cost quite a bit in lost physician time or increased staff hours.

We just had a meeting on this very issue yesterday within our office.

One suggested to have docs fill out a form with all the info to speed up

the staff who handle this. I prefer having this done by the docs with

the patient in the room. That way we get paid (a little bit) for our

time and the patient is involved, or at least exposed, to the hassles of

their insurance. However, I've lost two patients this year who were

annoyed that I make them come in for forms or prior authorizations.

[Guest guest]

But talking to the so called pharmacist made no difference, seems to have been a checklister too...

Sangeetha Murthy

> ,

> > Here is the problem with the fax. It totally eliminates any contact with the patient or the patient advocate. Why would an administrator anywhere give your patient the benefit of the doubt and allow a medication request to go through if they a) never have to meet the person and never have to even talk to that person or his angry doctor. It’s kind of like when people write ugly e-mails—as long as it is shrouded in the technology world and they are not actually talking to the person, then people say really evil and hateful things. They do it because they have a total disconnect from the actual person (full of emotions and in this case medical problems). Adding the fax only adds another barrier to overcome.

> > > > > > From: [mailto: ] On Behalf Of Bleiweiss

> Sent: Wednesday, April 20, 2011 11:36 PM> To: > Subject: Re: Actual prior auth call

> > > > > > And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly...

> > > > I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format....

> > > > > > > > _____ > > > To: " " < >

> Sent: Wed, April 20, 2011 10:52:49 PM> Subject: Re: Actual prior auth call> > > > I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back

> > My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. > > > > > >

> > > > Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

> > Me: I give all the information> > Operator#1: Great, what can I do for you today?> > Me: I need a prior auth done for Januvia.> > Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

> > Me: Great.> > Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

> > Me: Ok, and I give all the information over again.> > Operator #2: What can I do for you today?> > Me: I would like to complete a prior auth for Januvia.> > Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

> > Me: No, I would rather do it over the phone.> > Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

> > Me: No. He got severe diarrhea from the metformin.> > Operator#2: Did the patient have elevated liver function tests on metformin?> > Me: No. He got severe diarrhea on the metformin.

> > Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?> > Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

> > Operator#2: I’m sorry, you have to answer yes or no.> > Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. > > Operator#2: Then the medication cannot be approved.

> > Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.> > Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

> > Me: Please.> > Operator#2: Thanks for your patience, the pharmacist is now on the line.> > Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

> > Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.> > Pharmacist: I’m sorry, I need a yes or no answer.

> > Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.> > Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. > > Me: Would you consider a treatment failure a contraindication?

> > Pharmacist: I’m sorry, I can’t help you answer the question.> > Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

> > Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.> > Me: Then the answer to the last question is yes.

> > Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.> > Operator #2: Is there anything else we can help you with today? No? Ok.

> > > > This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

> > > > >

[Guest guest]

Agreed, but at least she had to hear me yell and plead. Who knows, maybe she will try and change something internally. From: [mailto: ] On Behalf Of Sangeetha MurthySent: Thursday, April 21, 2011 11:17 AMTo: Subject: RE: Actual prior auth call But talking to the so called pharmacist made no difference, seems to have been a checklister too...Sangeetha Murthy> ,> > Here is the problem with the fax. It totally eliminates any contact with the patient or the patient advocate. Why would an administrator anywhere give your patient the benefit of the doubt and allow a medication request to go through if they a) never have to meet the person and never have to even talk to that person or his angry doctor. It’s kind of like when people write ugly e-mails—as long as it is shrouded in the technology world and they are not actually talking to the person, then people say really evil and hateful things. They do it because they have a total disconnect from the actual person (full of emotions and in this case medical problems). Adding the fax only adds another barrier to overcome.> > > > > > From: [mailto: ] On Behalf Of Bleiweiss> Sent: Wednesday, April 20, 2011 11:36 PM> To: > Subject: Re: Actual prior auth call> > > > > > And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly...> > > > I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format....> > > > > > > > _____ > > > To: " " < >> Sent: Wed, April 20, 2011 10:52:49 PM> Subject: Re: Actual prior auth call> > > > I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back > > My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. > > > > > > > > > > Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?> > Me: I give all the information> > Operator#1: Great, what can I do for you today?> > Me: I need a prior auth done for Januvia.> > Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.> > Me: Great.> > Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?> > Me: Ok, and I give all the information over again.> > Operator #2: What can I do for you today?> > Me: I would like to complete a prior auth for Januvia.> > Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?> > Me: No, I would rather do it over the phone.> > Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?> > Me: No. He got severe diarrhea from the metformin.> > Operator#2: Did the patient have elevated liver function tests on metformin?> > Me: No. He got severe diarrhea on the metformin.> > Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?> > Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.> > Operator#2: I’m sorry, you have to answer yes or no.> > Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. > > Operator#2: Then the medication cannot be approved.> > Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.> > Operator#2: I’m sorry sir, would you like to talk to the pharmacist?> > Me: Please.> > Operator#2: Thanks for your patience, the pharmacist is now on the line.> > Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?> > Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.> > Pharmacist: I’m sorry, I need a yes or no answer.> > Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.> > Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. > > Me: Would you consider a treatment failure a contraindication?> > Pharmacist: I’m sorry, I can’t help you answer the question.> > Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?> > Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.> > Me: Then the answer to the last question is yes.> > Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.> > Operator #2: Is there anything else we can help you with today? No? Ok.> > > > This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care. > > > > >

[Guest guest]

It is also what drives up the cost of health insurance and pharmaceuticals.

It is another version of third parties trying to make themselves seem important,

when all they do is get in the way of the delivery of care.

Horvitz, D.O.

stown, NJ

Founder of the Institute for Medical Wellness

www.drhorvitz.com

>

> Operator #1: Can I start with the patient's ID number? Now what is the

> patient's name and date of birth? Great, your first name, the doctor's name,

> the office number, the NPI number, the secure fax number, and oh, can you

> verify the office address?

>

> Me: I give all the information

>

> Operator#1: Great, what can I do for you today?

>

> Me: I need a prior auth done for Januvia.

>

> Operator #1: Well, my computer shows that does need a prior auth. You need

> to call another number to speak to the prior authorization department. That

> number is XXX, but I will connect you.

>

> Me: Great.

>

> Operator #2: Hello. Can I start with the patient's ID number? Now what is

> the patient's name and date of birth? Great, your first name, the doctor's

> name, the office number, the NPI number, the secure fax number, and oh, can

> you verify the office address?

>

> Me: Ok, and I give all the information over again.

>

> Operator #2: What can I do for you today?

>

> Me: I would like to complete a prior auth for Januvia.

>

> Operator#2: Great. Just hang on for a minute.Yes, it looks like that

> medication needs a prior authorization. Would you like me to fax the

> paperwork to you?

>

> Me: No, I would rather do it over the phone.

>

> Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on

> for one minute.Ok, Has the patient had a severe reaction to metformin

> including lactic acidosis or rhabdomyolosis?

>

> Me: No. He got severe diarrhea from the metformin.

>

> Operator#2: Did the patient have elevated liver function tests on metformin?

>

> Me: No. He got severe diarrhea on the metformin.

>

> Operator #2: Are the use of metformin and sulfonylureas contraindicated in

> this patient?

>

> Me: I would say that the metformin is as the patient got severe diarrhea. He

> is on the maximum dose of sulfonylurea and so I would say that it is more of

> a treatment failure than a contraindication.

>

> Operator#2: I'm sorry, you have to answer yes or no.

>

> Me: Well, I guess the answer would be " no " as he can still take

> sulfonylureas.

>

> Operator#2: Then the medication cannot be approved.

>

> Me: Wait, that is ridiculous! He can tolerate the medication but it is not

> effective as a solo agent. That last question makes no sense.

>

> Operator#2: I'm sorry sir, would you like to talk to the pharmacist?

>

> Me: Please.

>

> Operator#2: Thanks for your patience, the pharmacist is now on the line.

>

> Pharmacist: I hear you are having a problem with Question number 3. Is the

> patient unable to tolerate both metformin and sulfonylureas?

>

> Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can

> tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to

> lower the sugar further.

>

> Pharmacist: I'm sorry, I need a yes or no answer.

>

> Me: But I can't answer yes or no. It is a 2 part question-and the answers

> are different.

>

> Pharmacist: I'm sorry, I can't help you answer the question. Is the answer

> yes or no.

>

> Me: Would you consider a treatment failure a contraindication?

>

> Pharmacist: I'm sorry, I can't help you answer the question.

>

> Me: If I say that the patient has a contraindication to sulfonylureas, what

> will happen the next time I try to fill his glipizide?

>

> Pharmacist: That medication does not need prior authorization. The only

> notes we have are that the patient cannot tolerate metformin and that it

> gives him diarrhea.

>

> Me: Then the answer to the last question is yes.

>

> Pharmacist: Great. The medication has been approved for a year. His copay

> will be $9/month, and he can pick it up at any participating pharmacy in 5

> minutes.

>

> Operator #2: Is there anything else we can help you with today? No? Ok.

>

>

>

> This 15 minute conversation sums up the useless insanity which is eating up

> more and more administrative time every year my practice is open. It also is

> what drives physicians out of primary care.

>

>

>

[Guest guest]

J Sadly, I remain one. From: [mailto: ] On Behalf Of Sangeetha MurthySent: Thursday, April 21, 2011 11:34 AMTo: Subject: Re: Actual prior auth call You ARE an optimist arent you? Agreed, but at least she had to hear me yell and plead. Who knows, maybe she will try and change something internally. From: [mailto: ] On Behalf Of Sangeetha MurthySent: Thursday, April 21, 2011 11:17 AMTo: Subject: RE: Actual prior auth call But talking to the so called pharmacist made no difference, seems to have been a checklister too...Sangeetha Murthy> ,> > Here is the problem with the fax. It totally eliminates any contact with the patient or the patient advocate. Why would an administrator anywhere give your patient the benefit of the doubt and allow a medication request to go through if they a) never have to meet the person and never have to even talk to that person or his angry doctor. It’s kind of like when people write ugly e-mails—as long as it is shrouded in the technology world and they are not actually talking to the person, then people say really evil and hateful things. They do it because they have a total disconnect from the actual person (full of emotions and in this case medical problems). Adding the fax only adds another barrier to overcome.> > > > > > From: [mailto: ] On Behalf Of Bleiweiss> Sent: Wednesday, April 20, 2011 11:36 PM> To: > Subject: Re: Actual prior auth call> > > > > > And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly...> > > > I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format....> > > > > > > > _____ > > > To: " " < >> Sent: Wed, April 20, 2011 10:52:49 PM> Subject: Re: Actual prior auth call> > > > I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back > > My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. > > > > > > > > > > Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?> > Me: I give all the information> > Operator#1: Great, what can I do for you today?> > Me: I need a prior auth done for Januvia.> > Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.> > Me: Great.> > Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?> > Me: Ok, and I give all the information over again.> > Operator #2: What can I do for you today?> > Me: I would like to complete a prior auth for Januvia.> > Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?> > Me: No, I would rather do it over the phone.> > Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?> > Me: No. He got severe diarrhea from the metformin.> > Operator#2: Did the patient have elevated liver function tests on metformin?> > Me: No. He got severe diarrhea on the metformin.> > Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?> > Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.> > Operator#2: I’m sorry, you have to answer yes or no.> > Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. > > Operator#2: Then the medication cannot be approved.> > Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.> > Operator#2: I’m sorry sir, would you like to talk to the pharmacist?> > Me: Please.> > Operator#2: Thanks for your patience, the pharmacist is now on the line.> > Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?> > Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.> > Pharmacist: I’m sorry, I need a yes or no answer.> > Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.> > Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. > > Me: Would you consider a treatment failure a contraindication?> > Pharmacist: I’m sorry, I can’t help you answer the question.> > Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?> > Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.> > Me: Then the answer to the last question is yes.> > Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.> > Operator #2: Is there anything else we can help you with today? No? Ok.> > > > This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care. > > > > > -- Sangeetha

[Guest guest]

You ARE an optimist arent you?

 

Agreed, but at least she had to hear me yell and plead. Who knows, maybe she will try and change something internally.

 From: [mailto: ] On Behalf Of Sangeetha Murthy

Sent: Thursday, April 21, 2011 11:17 AMTo: Subject: RE: Actual prior auth call

   But talking to the so called pharmacist made no difference, seems to have been a checklister too...

Sangeetha Murthy

> ,> > Here is the problem with the fax. It totally eliminates any contact with the patient or the patient advocate. Why would an administrator anywhere give your patient the benefit of the doubt and allow a medication request to go through if they a) never have to meet the person and never have to even talk to that person or his angry doctor. It’s kind of like when people write ugly e-mails—as long as it is shrouded in the technology world and they are not actually talking to the person, then people say really evil and hateful things. They do it because they have a total disconnect from the actual person (full of emotions and in this case medical problems). Adding the fax only adds another barrier to overcome.

> > > > > > From: [mailto: ] On Behalf Of Bleiweiss

> Sent: Wednesday, April 20, 2011 11:36 PM> To: > Subject: Re: Actual prior auth call

> > > > > > And look at these unanticipateable clinically based questions that make it pretty much impossible for an MA or a Non-Medical person like my fairly intelligent self to even concieve doing such things for our docs. So you either need to have a fully capable Clinical level person like a Nurse or PA, OR THE DOC themselves deal with this or its one flushed prior auth. This is why I don't even try to do these for ... I would mess it up very quickly...

> > > > I wonder what would have happened if you had them fax the paperwork and you did answer in a two part, actual real world clinical way instead of the checklist, ones and zeros, data collection format....

> > > > > > > > _____ > > > To: " " < >

> Sent: Wed, April 20, 2011 10:52:49 PM> Subject: Re: Actual prior auth call> > > > I would be laughing if it weren't so true. All prior auth's are done by our nurse, who was out today. Thankfully, we only had one request today and it can wait until tomorrow when she comes back

> > My wish for healthcare is that doctors can go back to being doctors and not be in between patients and their insurance any more. > > > > > >

> > > > Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

> > Me: I give all the information> > Operator#1: Great, what can I do for you today?> > Me: I need a prior auth done for Januvia.> > Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

> > Me: Great.> > Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

> > Me: Ok, and I give all the information over again.> > Operator #2: What can I do for you today?> > Me: I would like to complete a prior auth for Januvia.> > Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

> > Me: No, I would rather do it over the phone.> > Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

> > Me: No. He got severe diarrhea from the metformin.> > Operator#2: Did the patient have elevated liver function tests on metformin?> > Me: No. He got severe diarrhea on the metformin.

> > Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?> > Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

> > Operator#2: I’m sorry, you have to answer yes or no.> > Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. > > Operator#2: Then the medication cannot be approved.

> > Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.> > Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

> > Me: Please.> > Operator#2: Thanks for your patience, the pharmacist is now on the line.> > Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

> > Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.> > Pharmacist: I’m sorry, I need a yes or no answer.

> > Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.> > Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. > > Me: Would you consider a treatment failure a contraindication?

> > Pharmacist: I’m sorry, I can’t help you answer the question.> > Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

> > Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.> > Me: Then the answer to the last question is yes.

> > Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.> > Operator #2: Is there anything else we can help you with today? No? Ok.

> > > > This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

> > > > >

-- Sangeetha

[Guest guest]

The prior auth thing is reaching epidemic proportions. My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks. She's on a multishot per day regimen and 28 weeks along. She happens to have Medicare because she's disabled. Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory. We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare. Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things. Everything else needs a prior auth.

Best,

Ben

Subject: Actual prior auth callTo: Date: Wednesday, April 20, 2011, 9:26 PM

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no†as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

[Guest guest]

When I testified last year at the state capitol they discussed this  stuff its " provider abrasion "  that's what is going onBlue Cross( and others)  knows they get  provider abrasion when they do this

I almost leapt out of my chair to throttle the woman who  described it .. that's the spin on this stuff.

 

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Ben

Subject: Actual prior auth call

To: Date: Wednesday, April 20, 2011, 9:26 PM

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

--      MD          ph    fax

[Guest guest]

can you explain that/ Do they want us to be abraded? or they are afraid of provider abrasion? ( which is oddly what googling says, which is ridiculous, NOBODY is afraid of us)

 

When I testified last year at the state capitol they discussed this  stuff its " provider abrasion "  that's what is going onBlue Cross( and others)  knows they get  provider abrasion

 when they do this

I almost leapt out of my chair to throttle the woman who  described it .. that's the spin on this stuff.

 

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Ben

Subject: Actual prior auth call

To: Date: Wednesday, April 20, 2011, 9:26 PM

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

--      MD          ph    fax

-- Sangeetha

[Guest guest]

I would have answered, he can't tolerate sulfonylureas (at any more of a higher dose). Incomplete sentence. That's all. Any way Glipizine is a $4 Target drug, so pt can by pass any insurance band

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas.

Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.

Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above.

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[Guest guest]

So does that mean that if the provider is " abraded " that we won't do it and thus the insurance gets out of paying?!?

 

When I testified last year at the state capitol they discussed this  stuff its " provider abrasion "  that's what is going onBlue Cross( and others)  knows they get  provider abrasion

 when they do thisI almost leapt out of my chair to throttle the woman who  described it .. that's the spin on this stuff.

 

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Ben

Subject: Actual prior auth call

To: Date: Wednesday, April 20, 2011, 9:26 PM

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas.

Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.

Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

--      MD          ph    fax

--

Pratt

Oak Tree Internal Medicine, PC

2301 Camino Ramon, Suite 290

San Ramon, CA 94583

p.

f.

c.

www.prattmd.info

 

[Guest guest]

were not afraid  Didn't give  you know what Just named it.

 

can you explain that/ Do they want us to be abraded? or they are afraid of provider abrasion? ( which is oddly what googling says, which is ridiculous, NOBODY is afraid of us)

 

When I testified last year at the state capitol they discussed this  stuff its " provider abrasion "  that's what is going onBlue Cross( and others)  knows they get  provider abrasion

 when they do this

I almost leapt out of my chair to throttle the woman who  described it .. that's the spin on this stuff.

 

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Ben

Subject: Actual prior auth call

To: Date: Wednesday, April 20, 2011, 9:26 PM

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas. Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no. Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

--      MD          ph    fax

-- Sangeetha

--      MD          ph    fax

[Guest guest]

" we get  provider abrasion  when we do XYZ "  I took it as  oh we the wonderful insurers try to reduce costs because   those docs order too many things that cost alot but when we the wonderful insurers  do XYZ we  get   provider abrasion

 

So does that mean that if the provider is " abraded " that we won't do it and thus the insurance gets out of paying?!?

 

When I testified last year at the state capitol they discussed this  stuff its " provider abrasion "  that's what is going onBlue Cross( and others)  knows they get  provider abrasion

 when they do thisI almost leapt out of my chair to throttle the woman who  described it .. that's the spin on this stuff.

 

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Ben

Subject: Actual prior auth call

To: Date: Wednesday, April 20, 2011, 9:26 PM

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas.

Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.

Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

--      MD         

ph    fax

--

Pratt

Oak Tree Internal Medicine, PC

2301 Camino Ramon, Suite 290

San Ramon, CA 94583

p.

f.

c.

www.prattmd.info

 

--      MD          ph    fax

[Guest guest]

I too would love to hear more about this new term, Provider Abrasion and what is the most accurate definition of it, what is their stance on it, are they attempting to do this to affect and direct our behavior, ala Cat Herbing might we say??? Are they complaining about it as though it is our fault that we are so upset and "Abraded" from our Scrapes with them all the time??? Are they trying to imply that they are aware of it and BS'ing regulators and officials that they are doing "All they can" to minimize and "simplify" their innane processes for us poor Too Sensitive doctors????

BTW, not sure if others here know this one but on the Worker's Comp side of things when they dispute an injured worker's claims so as to delay their checks to suppliment their lost wages, the insider term is "Starvation Therapy"!!!! I learned that one a long while ago, way before I ever worked in this field directly. It made my blood boil so high, I almost had a stroke... Imagine all the horrible negative images and concepts that such a term implies including that there are NO validly injured or sick folks who are deserving of being properly paid their bought and paid for benefits if and when they have to go out from work.... And that the best solution is to starve them out of their Malingering.... And that is the term they use to describe an injured worker who won't get well and back to work, that is the verb, action and they are themselves, Malingerers.... God I hate these people so very much... Just how do they wake up and

actually look themselves in the mirror each morning when they shave or brush their teeth????

To: Sent: Thu, April 21, 2011 12:19:09 PMSubject: Re: Actual prior auth call

When I testified last year at the state capitol they discussed this stuff its "provider abrasion" that's what is going onBlue Cross( and others) knows they get provider abrasion when they do thisI almost leapt out of my chair to throttle the woman who described it .. that's the spin on this stuff.

The prior auth thing is reaching epidemic proportions. My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks. She's on a multishot per day regimen and 28 weeks along. She happens to have Medicare because she's disabled. Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory. We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare. Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things. Everything else needs a prior auth.

Best,

Ben

Subject: Actual prior auth callTo: Date: Wednesday, April 20, 2011, 9:26 PM

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no†as he can still take sulfonylureas.

Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.

Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

-- MD ph fax

[Guest guest]

that's all I know   It is what they use to describe pushback from docs

 

    I too would love to hear more about this new term, Provider Abrasion and what is the most accurate definition of it, what is their stance on it, are they attempting to do this to affect and direct our behavior, ala Cat Herbing might we say??? Are they complaining about it as though it is our fault that we are so upset and " Abraded " from our Scrapes with them all the time??? Are they trying to imply that they are aware of it and BS'ing regulators and officials that they are doing " All they can " to minimize and " simplify " their innane processes for us poor Too Sensitive doctors????

 

    BTW, not sure if others here know this one but on the Worker's Comp side of things when they dispute an injured worker's claims so as to delay their checks to suppliment their lost wages, the insider term is " Starvation Therapy " !!!! I learned that one a long while ago, way before I ever worked in this field directly. It made my blood boil so high, I almost had a stroke... Imagine all the horrible negative images and concepts that such a term implies including that there are NO validly injured or sick folks who are deserving of being properly paid their bought and paid for benefits if and when they have to go out from work.... And that the best solution is to starve them out of their Malingering.... And that is the term they use to describe an injured worker who won't get well and back to work, that is the verb, action and they are themselves, Malingerers.... God I hate these people so very much... Just how do they wake up and

actually look themselves in the mirror each morning when they shave or brush their teeth????

 

To:

Sent: Thu, April 21, 2011 12:19:09 PMSubject: Re: Actual prior auth call

 

When I testified last year at the state capitol they discussed this  stuff its " provider abrasion "  that's what is going onBlue Cross( and others)  knows they get  provider abrasion

 when they do thisI almost leapt out of my chair to throttle the woman who  described it .. that's the spin on this stuff.

 

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Ben

Subject: Actual prior auth callTo: Date: Wednesday, April 20, 2011, 9:26 PM

 

Operator #1: Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: I give all the information

Operator#1: Great, what can I do for you today?

Me: I need a prior auth done for Januvia.

Operator #1: Well, my computer shows that does need a prior auth. You need to call another number to speak to the prior authorization department. That number is XXX, but I will connect you.

Me: Great.

Operator #2: Hello. Can I start with the patient’s ID number? Now what is the patient’s name and date of birth? Great, your first name, the doctor’s name, the office number, the NPI number, the secure fax number, and oh, can you verify the office address?

Me: Ok, and I give all the information over again.

Operator #2: What can I do for you today?

Me: I would like to complete a prior auth for Januvia.

Operator#2: Great. Just hang on for a minute…Yes, it looks like that medication needs a prior authorization. Would you like me to fax the paperwork to you?

Me: No, I would rather do it over the phone.

Operator#2: Yes, sir, we can do that. Let me ask a few questions. Hang on for one minute…Ok, Has the patient had a severe reaction to metformin including lactic acidosis or rhabdomyolosis?

Me: No. He got severe diarrhea from the metformin.

Operator#2: Did the patient have elevated liver function tests on metformin?

Me: No. He got severe diarrhea on the metformin.

Operator #2: Are the use of metformin and sulfonylureas contraindicated in this patient?

Me: I would say that the metformin is as the patient got severe diarrhea. He is on the maximum dose of sulfonylurea and so I would say that it is more of a treatment failure than a contraindication.

Operator#2: I’m sorry, you have to answer yes or no.

Me: Well, I guess the answer would be “no” as he can still take sulfonylureas.

Operator#2: Then the medication cannot be approved.

Me: Wait, that is ridiculous! He can tolerate the medication but it is not effective as a solo agent. That last question makes no sense.

Operator#2: I’m sorry sir, would you like to talk to the pharmacist?

Me: Please.

Operator#2: Thanks for your patience, the pharmacist is now on the line.

Pharmacist: I hear you are having a problem with Question number 3. Is the patient unable to tolerate both metformin and sulfonylureas?

Me: Well, the patient cannot tolerate metformin due to diarrhea, but he can tolerate sulfonylureas as he is on the maximum dose. I am adding Januvia to lower the sugar further.

Pharmacist: I’m sorry, I need a yes or no answer.

Me: But I can’t answer yes or no. It is a 2 part question—and the answers are different.

Pharmacist: I’m sorry, I can’t help you answer the question. Is the answer yes or no.

Me: Would you consider a treatment failure a contraindication?

Pharmacist: I’m sorry, I can’t help you answer the question.

Me: If I say that the patient has a contraindication to sulfonylureas, what will happen the next time I try to fill his glipizide?

Pharmacist: That medication does not need prior authorization. The only notes we have are that the patient cannot tolerate metformin and that it gives him diarrhea.

Me: Then the answer to the last question is yes.

Pharmacist: Great. The medication has been approved for a year. His copay will be $9/month, and he can pick it up at any participating pharmacy in 5 minutes.

Operator #2: Is there anything else we can help you with today? No? Ok.

 

This 15 minute conversation sums up the useless insanity which is eating up more and more administrative time every year my practice is open. It also is what drives physicians out of primary care.

--      MD          ph    fax

--      MD          ph    fax

[Guest guest]

Patients need an appointment for forms and prescriptions (prior auth is done at time of visit).

Yes, some leave but I have adopted the line given to me here, "not a good fit."

To: Sent: Thu, April 21, 2011 11:04:33 AMSubject: Re: Actual prior auth callSo what's the consensus among IMPs on how to handle this stuff? It can cost quite a bit in lost physician time or increased staff hours.We just had a meeting on this very issue yesterday within our office. One suggested to have docs fill out a form with all the info to speed up the staff who handle this. I prefer having this done by the docs with the patient in the room. That way we get paid (a little bit) for our time and the patient is involved, or at least exposed, to the hassles of their

insurance. However, I've lost two patients this year who were annoyed that I make them come in for forms or prior authorizations.------------------------------------

[Guest guest]

The prior auth thing is reaching epidemic proportions.  My office has been trying to get diabetic test strips for a pregnant lady on insulin who's been out of strips for 2 weeks.  She's on a multishot per day regimen and 28 weeks along.  She happens to have Medicare because she's disabled.  Talking to the pharmacist has been no help despite multiple calls and working up the food chain at the denial factory.  We are at the level of calling the State Insurance commisioner and the our state representative's office to complain as this prior auth entity is somehow contracted with Medicare.  Also news this week is that Medicaid is tightening up what they'll allow for ADD meds and antidepressants to about 3-4 generic things.  Everything else needs a prior auth. 

Best,

Benhttp://www.ncbi.nlm.nih.gov/pubmed/9099125 

Self monitoring of glucose by people with diabetes: evidence based practice.

---Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR.

[Guest guest]

Graham, I think of Gestational Diabetes as a different animal than a mild type 2 patient that may not need monitoring beyond the occasional check. http://www.medscape.com/viewarticle/710578_5Monitoring of Maternal GlycemiaThe ADA's gestational diabetes position statement of 2004 encourages women to conduct daily self-monitoring of blood glucose (SMBG).[11] The exact methods for maternal glucose monitoring, including devices used and frequency and timing of blood collection, are not yet clear and remain an area of active research. The ADA 2009 Standards of Care suggests that the methods and frequency of blood glucose monitoring be designed around the needs of the individual patient.[1] The goal is to maintain euglycemia and avoid complications associated with hyperglycemic and

hypoglycemic episodes. It is most commonly suggested that patients with GDM perform SMBG three to four times daily. The ADA 2009 Standards of Care does not comment on postprandial versus fasting or preprandial SMBG levels specifically. The ADA simply states that to achieve postprandial glucose goals, postprandial SMBG may be appropriate. A study by De Veciana et al concluded that SMBG in patients with GDM should consist of fasting, preprandial, and postprandial readings.[13] These result in improved glycemic control in women with GDM who require insulin and lead to reduced complications for both mother and child. In particular, postprandial blood glucose levels that are utilized to alter therapy are associated with fewer incidences of macrosomia, fewer cesarean deliveries, and

overall improved glycemic control.[13]Subject: Re: Actual prior auth callTo: Date: Saturday, April 23, 2011, 8:44 PM

http://www.ncbi.nlm.nih.gov/pubmed/9099125

Self monitoring of glucose by people with diabetes: evidence based practice.

---Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR.

[Guest guest]

Ben I think I read something recently that suggested that for most patients urine monitoring was just as good as using a meter.  Of course I can't find the reference and so just posted that older one.

It surprised me but I guess I shouldn't as lots of things we believe are not rigorously shown to be true.Urine testing is much cheaper than using meters and special strips.  The companies make so much money from the strips they can afford to give the meters away for free.   I gather it's now getting hard to get urine strips that you can read with your eyes instead of a machine, and this increases the costs.  And for 3rd world countries it's a disaster.

As always, question everything

Graham, I think of Gestational Diabetes as a different animal than a mild type 2 patient that may not need monitoring beyond the occasional check.  

http://www.medscape.com/viewarticle/710578_5

Monitoring of Maternal Glycemia

The ADA's gestational diabetes position statement of 2004 encourages women to conduct daily self-monitoring of blood glucose (SMBG).[11] The exact methods for maternal glucose monitoring, including devices used and frequency and timing of blood collection, are not yet clear and remain an area of active research. The ADA 2009 Standards of Care suggests that the methods and frequency of blood glucose monitoring be designed around the needs of the individual patient.[1] The goal is to maintain euglycemia and avoid complications associated with hyperglycemic and

hypoglycemic episodes. It is most commonly suggested that patients with GDM perform SMBG three to four times daily. The ADA 2009 Standards of Care does not comment on postprandial versus fasting or preprandial SMBG levels specifically. The ADA simply states that to achieve postprandial glucose goals, postprandial SMBG may be appropriate. A study by De Veciana et al concluded that SMBG in patients with GDM should consist of fasting, preprandial, and postprandial readings.[13] These result in improved glycemic control in women with GDM who require insulin and lead to reduced complications for both mother and child. In particular, postprandial blood glucose levels that are utilized to alter therapy are associated with fewer incidences of macrosomia, fewer cesarean deliveries, and

overall improved glycemic control.[13]

Subject: Re: Actual prior auth callTo:

Date: Saturday, April 23, 2011, 8:44 PM

 

http://www.ncbi.nlm.nih.gov/pubmed/9099125 

Self monitoring of glucose by people with diabetes: evidence based practice.

---Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR.

-- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR.

[Guest guest]

Urine glucose monitoring.Couldn't find much in the 2000's.Mostly 1980's and 1990's.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127139/pdf/9251553.pdf

Ethiop Med J. 1998 Apr;36(2):93-9.

Urine glucose testing: another look at its relevance when blood glucose monitoring is unaffordable.

Feleke Y, Abdulkadir J.

SourceDepartment of Internal Medicine, Faculty of Medicine, Addis Ababa University.

Abstract

The reliability of urine glucose testing to monitor diabetic control was investigated in patients attending the Diabetic Clinic of the Tikur Anbassa Hospital in Addis Ababa between October 1994 and January 1995 with the aim of utilising it for those with a normal renal threshold who cannot afford the cost of home blood glucose monitoring. Clinically important fasting blood glucose values were taken as those > 180 mg/dl and important urine glucose values as those > or = 0.25% by Clinitest. Capillary blood glucose was determined by visual and metre readings. Urine was tested for glucose by the standard Clinitest method. There were 265 patients, 126 IDDM and 139 NIDDM. Urine glucose corresponded satisfactorily with FBG in 80% of the patients. The sensitivity, specificity, positive and negative predictive values of urine glucose results by Clinitest in comparison with FBG by metre determination were 71%, 90%, 90% and 70% and by visual determination 71%, 86%, 80%, 79% respectively. On the basis of these results we conclude that urine glucose testing by Clinitest provides reliable information in more than 70% of our diabetic patients the majority of whom cannot afford the cost of home blood glucose monitoring.

Diabetes Care. 1990 Oct;13(10):1044-50.

Impact of glucose self-monitoring on non-insulin-treated patients with type II diabetes mellitus. Randomized controlled trial comparing blood and urine testing.

BT, DeLong ER, Feussner JR.

SourceHealth Services Research and Development Field Program, Durham Veterans Administration Medical Center, NC 27705.

AbstractThe goal of this study was to compare the relative efficacy and cost of self-monitoring of blood glucose (SMBG) with routine urine testing in the management of patients with type II (non-insulin-dependent) diabetes mellitus not treated with insulin. Fifty-four patients with type II diabetes mellitus, not treated with insulin, who had inadequate glucose control on diet alone or diet and oral hypoglycemic agents were studied. Patients performed SMBG or urine glucose testing as part of a standardized treatment program that also included diet and exercise counseling. During the 6-mo study, both the urine-testing and SMBG groups showed similar improvement in glycemic control; within each group, there were significant improvements in fasting plasma glucose (reduction of 1.4 +/- 3.2 mM, P less than 0.03) and glycosylated hemoglobin (reduction of 2.0 +/- 3.4%, P less than 0.01) levels. Seventeen (31%) of 54 patients actually normalized their glycosylated hemoglobin values, 9 in the urine-testing group and 8 in the SMBG group. Comparisons between the urine-testing and SMBG groups showed no significant differences in mean fasting plasma glucose (P greater than 0.86), glycosylated hemoglobin (P greater than 0.95), or weight (P greater than 0.19). In patients with type II diabetes mellitus not treated with insulin, SMBG is no more effective, but is 8-12 times more expensive, than urine testing in facilitating improved glycemic control. Our results do not support widespread use of SMBG in diabetic patients not treated with insulin.

Diabetologia. 1994 Feb;37(2):170-6.

Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow--blood glucose versus urine glucose self-monitoring.

Starostina EG, Antsiferov M, Galstyan GR, Trautner C, Jörgens V, Bott U, Mühlhauser I, Berger M, Dedov II.

SourceDiabetes Care and Education Unit, Russian Academy of Medical Sciences, Moscow.

Abstract

In a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose self-monitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followed-up for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 rubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [uGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2% after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12.3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year).(ABSTRACT TRUNCATED AT 250 WORDS)

Dog and Cat's.  :-)

A justification for urine glucose monitoring in the diabetic dog and cat

Schaer J Am Anim Hosp Assoc.2001; 37: 311-312 

BMJ. 1997 Jul 19;315(7101):185.

Self monitoring of glucose by people with diabetes. Patients with non-insulin dependent diabetes should monitor urine urine rather than blood glucose.

Chantelau E, Nowicki S.

J Fam Pract. 1992 Apr;34(4):495-7.

Urine glucose testing: reliable backup for whole blood glucose monitoring.

Kabadi UM.

SourceEndocrinology Section, VA Medical Center, Phoenix, AZ 85012.

Abstract

Urine glucose testing has been deemed by some to be nonessential in the management of diabetes mellitus since the technique and equipment for self-monitoring of blood glucose has become available. However, most physicians have experienced pitfalls in the management of diabetes mellitus when insulin dosage is adjusted daily based solely on the patient's monitoring of blood glucose. There have also been recent reports suggesting the use of urine glucose testing as a reliable and a reasonable alternative to monitoring of blood glucose in the management of diabetic subjects, including those using insulin as the mode of therapy. In this report, we describe a patient in whom diabetic ketoacidosis occurred during hospitalization as a result of inadequate insulin administration due to inaccurate capillary blood glucose test results. Furthermore, urine glucose and ketone values obtained simultaneously had been disregarded. If insulin therapy had been adjusted according to urine glucose results rather than blood glucose readings, diabetic ketoacidosis could have been averted in this patient. Urine glucose testing may provide a reliable backup for suspect whole blood glucose values and may prevent catastrophic events requiring expensive hospitalization. This report also delineates several potential procedural problems that exist in the technique of whole blood glucose monitoring and provides recommendations to overcome these deficiencies.

Locke, MD

 

Ben I think I read something recently that suggested that for most patients urine monitoring was just as good as using a meter.  Of course I can't find the reference and so just posted that older one.

It surprised me but I guess I shouldn't as lots of things we believe are not rigorously shown to be true.Urine testing is much cheaper than using meters and special strips.  The companies make so much money from the strips they can afford to give the meters away for free.   I gather it's now getting hard to get urine strips that you can read with your eyes instead of a machine, and this increases the costs.  And for 3rd world countries it's a disaster.

As always, question everything