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.
I'm also in outpatient specialty so I've got a lot of experience with PAs. With experience the PA process will come a little quicker as you'll know what's likely to be approved or not. A common reason I've found that extremity CT/MRI will get denied is lack of a recent xray, lack of recent physical therapy, or lack of trial of medication, so make sure you scan the chart for these. Beyond that, I've found it helpful to reference general insurance guidelines you can find online before making the PA attempt. That way you can scan the chart for specific things and be fully prepared with what they will likely need for approval before they ask you all the questions.
I usually don't take the time to specifically look for the requirements of the patient's particular insurance company, but I'll go off of general guidelines like above. This has served me really well. Sometimes I've found that the main reason we're ordering an imaging scan isn't listed on the requirements, but, the patient happens to meet criteria in another way (i.e. diabetes or something).
For medication denials make sure you always put if it is a continuing medication. They want to see previous medication trials so have a good system for finding this information. I'm not sure what EMR system you use, but oftentimes a patient will tell the provider medications they've tried and failed in the past (which won't be listed in the medication section) and you'll find most of this in the provider's initial consult note, so always scan this section. The initial consult note holds so much pertinent information, always scan this (along with last office note) before any PA, they'll tell the doc things like previous physical therapy from other physician, length of time of the problem, major concerning symptoms like unable to drive due to dizziness, and previous imaging from other physicians, along with the previous meds. Sometimes there's not much info in the chart so I'll actually call the patient first to ask if they've tried ibuprofen, naproxen, etc in the past.
Some physicians are good at recommending home exercises. This is considered physician-guided/directed physical therapy which can help your case too.
If a drug entirely falls off formulary, you can sometimes find the insurance formulary online, or, what I usually do is call the pharmacist and ask for their recommendation. They work with this day in and day out so they generally know off the top of their head what will go through insurance. Then you can ask the doc if you can switch to that other med if its a general drug like for cholesterol. Often for specialty meds it is worth fighting to stay on the drug the patient's been on, because it usually takes a lot of time to find a specialty drug that works for the patient.
Oh! Also forgot to mention, if you didn't already know, Target and Wal-Mart have a huge list of basic generic $4 medications. I'm not sure which specialty you're in but the list includes drugs for pain, diabetes, bp meds, prednisone, etc. Target : Pharmacy : $4 generic drugs listed by condition
The $4 list is so nice because all the patient needs is a script, and the pharmacy charges a flat $4 fee, without running it through insurance, so you don't need to worry about approval. I've found these drugs to often be cheaper than people with insurance coverage who get the script from i.e. Walgreens. Many of my patients use the $4 list.
Money is a big thing for specialty patients because their specialty drugs can cost so much so any dollar saved helps a lot. One good thing about the specialty drugs though is that the very expensive ones often have assistance programs through the manufacturer, such as copay cards. They are such a lifesaver for the patients!
Hi there! I was just reviewing old posts and wanted to give an update on how things turned out.. The amount of prior authorizations has definitely declined since February and I've had a more manageable workload (whew!). One thing that really helped was mentioning to the doctors while seeing patients which medications for our specialty would likely be covered in that patient's formulary.. Most of the time they had no idea which ones would be easier to obtain and cheaper for the patient over others. I've also delegated more of the straightforward phone calls and tasks to the MAs which has been helpful in time management.
Thank you for all of the great advice. I really needed it at the time.
Sometimes, I'd use patient assistance cards until I could get PA approval. Don't forget about Wal-mart and target's $4 drugs. Some other suggestions would be to be sure you're using the appropriate diagnosis, and if applicable, be sure you're including documentation of failed trials of the formulary drugs. It does seem like you need some help.
PA's are horrible and I noticed a HUGE increase in them January 2, 2014. Some can be obtained online, some can have the form faxed over for you to fill out and submit at your convenience, but most require the oh-so-fun phone call. It's not the providers are all writing non-formulary meds, it's stupid insurance companies changing what is formulary and what isn't. Kaiser, for instance, will NOT cover a nasal steroid, but wants you to change it to a nasal antihistamine. No, if the pt needed a nasal antihistamine, doc would write for one. Plus, Medicaid pts need a new PA with almost every refill because they can change plans month-to-month (in my state there's 4 sub-plans under Medicaid) so the Wellcare PA won't cover a GBHC plan, etc. This year, Medicare pts with a script for albuterol inhalation solution for a nebulizer had to have the written dx and ICD-9 code in the sig line of the script or it was denied.
I wonder if all h3ll will break lose when we switch to icd-10 October 1st... I smell a storm coming! Like all the previously authorized meds will need new prior auths ::shudder::
The ICD-10 will make it harder for coding purposes. Our facility has built a cross-reference sheet to help go from 9 to 10 so you're not flipping through all 200,000 new codes. Existing PAs should be okay because it's already been approved for 6 months to one year, with a valid diagnosis, but new PAs will take more time. Everyone is required to start the ICD-10 next month.
Amistad, RN
131 Posts
Yeah I've started using cover my meds and it helps save some time, but the meds still get denied half the time. Oh well. :-P
Thanks for the encouragement guys!