Friday, January 17, 2014

Bureaucratic Nonsense

Had to fight off hematemesis today when I received a letter from a patient's insurance.
Mr. X has type 2 diabetes, and at his last visit with me two months ago, had complained of erectile dysfunction. His usual screening labs were negative and so we discussed the option of phosphodiesterase inhibitor therapy. He was keen on trying sildenafil, so I sent in a prescription.
He also had a history of coronary artery disease, for which he received 2 stents 9 years ago. He was prescribed sublingual nitroglycerin to be used only as needed if he had more chest pains. Which he never did since his intervention. But, like the obedient patient that he is, he kept refilling the nitro prescription his cardiologist gave him, "just in case". We discussed the side effects and the potential major interaction between these two agents, but felt that since he has never taken the nitro in the 9 years he has had a prescription, it would be OK taking sildenafil as needed.
And so, this started a bureaucratic roller coaster which is still in mediation. His insurance company said "No", because an astute clerk had noted nitro in his medlist. The fax had a number the physician or patient could call to appeal the denial, and to review the case with a medical reviewer.
Now, I can understand the concern seeing Viagra and nitro on the same list, so I called the 1-800 number to review with a pharmacist reviewer. And I clearly explained that although nitro is listed on his medlist, it is a PRN (as-needed) medication, one he has NEVER used in the 9 years he has had this. And I explained that the patient is aware never to take both medications at the same time. The pharmacist seemed understanding, and agreed it was OK and promised to relay this to the people who approve these things.
A week later, I receive another fax. No. Because your patient was noted to be on nitroglycerin.
Which prompted me to write a letter this time, again explaining that the nitro was a formality- though he was prescribed this, he had NEVER used it. While on the other hand his erectile dysfunction was significant enough to be causing quality-of-life issues. Explained that the patient is aware of the interactions. I signed and sent this letter off to Insurance Company From Hell.
And then today, I receive another letter. "Your appeal letter cannot be processed because you are not an authorized representative of the patient".
What the frak??? I am the prescriber, and by that alone, I am a representative of the patient. And if I wasn't authorized to be speaking for the patient, WTF did you send me those two faxes anyway??
Anyway, I was required to get the patient to sign a 4 page form, stating that I am indeed an authorized health representative for him.
Never mind that I've been his endocrinologist for the last 3 years.
And people wonder why they say that medicine would be a lot cheaper and simpler without insurance companies and lawyers.
Somehow, I'm not holding my breath that this will be approved.
(Next, I'll vent about formulary changes in the new year!)

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