Drowning in prior authorizations... Help!

[Amistad, RN]

Hi there! I'm a registered nurse with hospital experience who recently started working at a specialty practice. The first few months went well but I've recently felt like I'm unable to keep up with the work...

I'm responsible for rooming patients every 15-30 minutes for at least half the day, do telephone triage (about 30 calls a day), prep charts, and obtain prior auths or medical appeals... I've had a lot of trouble keeping up with the prior auths and I feel that the phone triage is suffering as well... It seems that after January 1st none of my patients' meds are covered and many appeals were denied. I've also had CT scans and MRIs denied recently... What the #*>%#* is going on?!

Is anyone in a similar situation or have some advice or words of encouragement? I feel like I made a mistake leaving hospital nursing even though I initially enjoyed working with patients in the outpatient setting.

[klone, MSN, RN]

Are you the only non-provider there? Who are the support staff? MAs? What do they do?

Why are your providers using so many non-formulary medications? Do they maybe need to have a list handy of medications that the insurance companies cover so they can choose from the formulary meds? How many different plans do you accept?

It's rare that we have many prior auths because our providers utilize generics and common drugs. The providers do their own prior auths.

[xoemmylouox, ASN, RN]

This happens every year in our office. Come Jan 1 meds that were covered, no longer are. Then you have to play the PA game or hope there is another option. It's beyond frustrating. It sounds like you need some help. Is there anyone else that can assist? Perhaps delegate some easier return calls to someone else?

[Amistad, RN]

I work between a few offices. we have 10+ providers, 2 MAs and 2 RNs including myself. I'm assigned to 2 of the MDs and take care of their refills, prior auths, phone calls, etc but we switch around rooming for all the doctors. Every time the docs order imaging (which at our practice is at least a few a day per MD) we need to call for prior auth except for Medicare part B members. We accept every type of insurance.. Medicare, Medicare, commercial insurance which makes things rather confusing. I also give IV infusions in the office a few times a week on top of everything else. I feel like what we need in this growing practice is more staff...

Do you have ideas as to where to find lists of formulary medications or tier 1 medications? Would the Medicare website have one?

Thank you for your ideas!!

[Amistad, RN]

I suppose I could delegate some tasks to the MAs.. I feel a little awkward doing this being new and I feel bad giving them more work to do. But I guess if it would benefit patients I should do that

[LFalcon]

This sounds just like my office. In try to use the online covermymeds but its still cumbersome. I don't think the drs in my office even know what prior auths are. I'd try to delegate to MAs anything you can. I've had allot of declines lately so do the appeals.. That is time consuming. Perhaps making someone a dedicated prior auth person?

[pfchang]

Rooming patients can be a MA task, no?

[ShortFuse_LPN, LPN]

Have you tried Covermymeds.com? I use this daily and it has been a life saver. It was shown to me by a drug rep and is supported by the major insurance companies.

[KelRN215, BSN, RN]

Managed care is the bane of my existence. I manage a program for pediatric home visits and some of these devil incarnate insurance companies will only approve nursing services for 2 weeks at a time... so for a kid with leukemia who we know is going to be on treatment for 2 years needing twice/week home nursing visits, it's a royal PITA and completely inefficient that every 2 weeks we have to play the game of "this kid is still being treated for leukemia... still getting labs and methotrexate pushes at home... still needs 2 visits/week."

The worst is when insurance companies, who know nothing about the patient other than what they've read on paper, are making decisions that have the potential to affect the patient's outcome. My cousin's kid has a rare metabolic disease and she just posted on facebook about how her insurance company denied a medication that her child is dependent on to live and that she's thriving on, saying it isn't medically necessary. It's complete BS. I can more or less guarantee that there are no pediatric metabolism specialists on staff at Blue Cross.

[fetch, BSN, RN]

I don't have any advice to offer, but you definitely have my sympathies! I worked as a pharmacy technician in nursing school and those prior authorizations are a pain in the tuckus for sure.

[Farawyn]

Yes, Prior Auths can kill a day. Part of the reason I left my old job was that it was just piled on. They finally gave the Prior Auths to the LPNs, but often times the company wanted to speak to an RN. I have no advice either. Good luck.

[toomuchbaloney]

I think you need to have a sit down discussion with the physician providers in the office to explore which tasks they might assign to the MAs so as to allow you the time to complete those things which require the critical thinking of an RN.