Posted on 09/17/2023 12:56:48 PM PDT by ConservativeMind
For patients with chronic conditions, including inflammatory bowel disease (IBD), newer drugs like biologics can be effective—but also expensive.
As a result, many insurance companies have limited access to these medications—and physicians are forced to jump through hoops. According to a recent story, insurance companies sometimes have their physicians reject claims without even reading them.
To address these challenges, Athos Bousvaros, MD, MPH is calling for change—and providing specialists with the tools they need to navigate an increasingly difficult approval process.
In a recent paper, Bousvaros and his colleague Stacy Kahn, MD detail how complicated the approval and denial process has become.
They point out that the market is largely dominated by three specialty pharmacy companies, and those three companies hold about 80% of the entire insurance industry market. Therefore, if a physician fills out the paperwork for one of these three big-box insurance companies but doesn't prescribe the medication exactly according to FDA guidelines, they're instantly denied. (It is unclear if the pharmacy benefit manager is denying medication after a proper medical review or if the denial is happening through software.)
These denials pose a particular challenge in pediatric medicine because many of the medications used to treat the same illnesses in adults are not yet FDA-approved for use in children and are prescribed "off-label."
While these challenges show no signs of going away, Bousvaros recommends three ways specialists can help patients access the medications they need.
Draw on resources. If you work within a larger hospital or health system, you may have access to resources for insurance denials.
Perfect your letter writing. The goal of a letter of medical necessity is to make the case for why a patient will benefit from the drug being prescribed.
Take a stand. Bousvaros encourages physicians to advocate for their patients.
(Excerpt) Read more at medicalxpress.com ...
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PBM’s need to be removed from the process all together. Insurance companies have no business deciding what medication a patient needs, that’s what their doctor is for. These PBM’s need to be reigned in, they’re killing people to save a few bucks.
At the pharmacy where I work, docs are constantly being sent Prior Authorization requests. I’ve seen months go by waiting to hear back from insurance companies for some people.
You can get meds covered this way if programs like GoodRX or Paramount are still too expensive, but we lose tons of money on GoodRX. The PBMs make all of the money, while the pharmacies make very little in comparison. $0.67 profit per RX at my company this last year.
And it’s a toss-up whether or not your insurance approves it at all.
Just what people need.... more BS administrative hoops to jump through. I suppose we pay insurance premiums so some nameless and faceless bureaucrat can say yea or nay regardless of what the doc, in his/her professional opinion, recommends.
Another broken system that is entirely too top heavy with useless eaters.
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