With all that’s going on in the world – wars, partisanship, a liar as the key witness in a trial with a lying ex- and maybe future president – this is not the biggest issue.
But it’s on the list of Top Five reasons to go, “WTF.”
About a month ago, as the weather warmed, I started playing golf again. I strained a muscle in my lower back (from my powerful swing being a little too powerful for so early in the season) and I wound up a couple weeks later at urgent care to get checked.
The professional diagnosis: I strained a muscle in my lower back.
Treatment: a muscle relaxer and an anti-inflammatory.
My pharmacy informed me my prescription was delayed because my insurer informed them the muscle relaxer requires “prior authorization.” (This notice came minutes after the prescription was received).
I call my insurer – CIGNA – to find out what that means and I first go through a long recorded introduction (in English and in Spanish) that lists categories I can press, none of which seem to include my question.
I finally get a human being -- or at least a call center voice. She nicely, calmly explains that I need prior authorization, which I knew.
Finding out what prior authorization means (beyond what I thought, which was my medical professional’s prescription) was next to impossible without listening to the patient young woman explain about Centers for Medicare and Medicaid Services (CMS) and other things written in her talking points. She also, nicely and inappropriately for this call, offered to make sure I have all my medications on hand by signing up for 90-day mail order prescriptions (which I had done years ago).
Still with me? It goes on.
Finally, she offers to transfer me to someone to whom I can appeal the prior authorization decision. I say please. (OK, at this stage politeness wasn’t part of my behavior anymore. I did not say please.) I wait two to three minutes and she comes back to ask if I’m still on the line. Yes, I reply with a bit of anger seeping into my voice. OK, she says, they’re busy I’ll be back to you. (My guess is those first two to three minutes are just to see if you’ll remain on hold.)
Eventually I get passed to another call center person who explains an appeal will take 72 hours. I hang up. Look up online the cost of the prescription -- $7.20. I go back to the pharmacy and say I’ll pay out of pocket and they hand me my pills.
Aggravating? Yes, but only $7.20 despite the prescription being in CIGNA’s formulary and me paying about $30 more a month for my coverage since CIGNA bought Express Scripts, which had been my insurer and, by the way, whose customer service was always fabulous.
But, I digress.
A few weeks later, back pain continues. I go see my doc. She prescribes a lidocaine patch. The pharmacy will have it in about an hour, she tells me. I get home and have an email telling me my prescription is delayed because I need prior authorization.
I call CIGNA, go through the same recordings, (can’t they just say, first, for English press 1, for Spanish press two? It would be better than to force a non-English or non-Spanish speaking person to listen to stuff they don’t understand before getting anywhere and to talk to a person they can’t understand either. But I digress.)
I go though all the same questions, up-selling pitches and, after two pauses of 2-3 minutes, get a fellow in the per-authorization appeals office.
He says an appeal can take 72 hours. I’m in pain now, I said. It could be gone in 72 hours. He doesn’t seem to care. Scratch that, he does not care.
We go through the questions, he gives me a case number and he asks me to give hm my doc’s name, fax number, phone number, address and first-born’s name (OK, I made that last one up). Then he tells me I need to call my doc and ask her to call CIGNA to pre-approve the approval she already approved by – writing a damn prescription!!!!!
Curious, I go back to the pharmacy and ask what happens after they inform me there’s a delay. They notify the doc, the pharmacist says, to get the “pre-authorization” that she already gave. Anther pharmacy worker at the drive-in window looks back at me and laughs that knowing laugh that says, “yes, it’s ridiculous isn’t it?”
Yes, it is.
The pharmacist tells me they should get the doc OK the next day. I think about paying out of pocket and then say to myself, “Self, why shell out $80 when you already pay for insurance???”
My wife, a former 30 year or so reporter from the old school (she does research) who has been to the end of the Internet and back, does her thing and comes up with class action lawsuits against CIGNA in California and others, about this problem because, apparently drug insurers are using Artificial Intelligence (AI) to reject such claims.
They use AI’s algorithms to automatically reject a medical professional’s prescription.
Short, simple English explanation: insurers use their AI predictive tools to deny claims and short-circuit physician review of those claims. They automatically deny thousands of claims at a time for treatments that don’t match certain preset criteria with no actual physician review.
Shorter, simpler explanation: They save lots of money by denying legitimate claims.
It’s the next day. The pharmacy has notified my doc. I notified my doc.
And I’m waiting. Maybe I’ll get an answer before I tee off in The Open at Royal Troon in July.
(I made that up. I won’t be playing The Open. Bad back, you know.)
(Oh, I also made up the part about my powerful golf swing. Just call me AI.)
But it’s on the list of Top Five reasons to go, “WTF.”
About a month ago, as the weather warmed, I started playing golf again. I strained a muscle in my lower back (from my powerful swing being a little too powerful for so early in the season) and I wound up a couple weeks later at urgent care to get checked.
The professional diagnosis: I strained a muscle in my lower back.
Treatment: a muscle relaxer and an anti-inflammatory.
My pharmacy informed me my prescription was delayed because my insurer informed them the muscle relaxer requires “prior authorization.” (This notice came minutes after the prescription was received).
I call my insurer – CIGNA – to find out what that means and I first go through a long recorded introduction (in English and in Spanish) that lists categories I can press, none of which seem to include my question.
I finally get a human being -- or at least a call center voice. She nicely, calmly explains that I need prior authorization, which I knew.
Finding out what prior authorization means (beyond what I thought, which was my medical professional’s prescription) was next to impossible without listening to the patient young woman explain about Centers for Medicare and Medicaid Services (CMS) and other things written in her talking points. She also, nicely and inappropriately for this call, offered to make sure I have all my medications on hand by signing up for 90-day mail order prescriptions (which I had done years ago).
Still with me? It goes on.
Finally, she offers to transfer me to someone to whom I can appeal the prior authorization decision. I say please. (OK, at this stage politeness wasn’t part of my behavior anymore. I did not say please.) I wait two to three minutes and she comes back to ask if I’m still on the line. Yes, I reply with a bit of anger seeping into my voice. OK, she says, they’re busy I’ll be back to you. (My guess is those first two to three minutes are just to see if you’ll remain on hold.)
Eventually I get passed to another call center person who explains an appeal will take 72 hours. I hang up. Look up online the cost of the prescription -- $7.20. I go back to the pharmacy and say I’ll pay out of pocket and they hand me my pills.
Aggravating? Yes, but only $7.20 despite the prescription being in CIGNA’s formulary and me paying about $30 more a month for my coverage since CIGNA bought Express Scripts, which had been my insurer and, by the way, whose customer service was always fabulous.
But, I digress.
A few weeks later, back pain continues. I go see my doc. She prescribes a lidocaine patch. The pharmacy will have it in about an hour, she tells me. I get home and have an email telling me my prescription is delayed because I need prior authorization.
I call CIGNA, go through the same recordings, (can’t they just say, first, for English press 1, for Spanish press two? It would be better than to force a non-English or non-Spanish speaking person to listen to stuff they don’t understand before getting anywhere and to talk to a person they can’t understand either. But I digress.)
I go though all the same questions, up-selling pitches and, after two pauses of 2-3 minutes, get a fellow in the per-authorization appeals office.
He says an appeal can take 72 hours. I’m in pain now, I said. It could be gone in 72 hours. He doesn’t seem to care. Scratch that, he does not care.
We go through the questions, he gives me a case number and he asks me to give hm my doc’s name, fax number, phone number, address and first-born’s name (OK, I made that last one up). Then he tells me I need to call my doc and ask her to call CIGNA to pre-approve the approval she already approved by – writing a damn prescription!!!!!
Curious, I go back to the pharmacy and ask what happens after they inform me there’s a delay. They notify the doc, the pharmacist says, to get the “pre-authorization” that she already gave. Anther pharmacy worker at the drive-in window looks back at me and laughs that knowing laugh that says, “yes, it’s ridiculous isn’t it?”
Yes, it is.
The pharmacist tells me they should get the doc OK the next day. I think about paying out of pocket and then say to myself, “Self, why shell out $80 when you already pay for insurance???”
My wife, a former 30 year or so reporter from the old school (she does research) who has been to the end of the Internet and back, does her thing and comes up with class action lawsuits against CIGNA in California and others, about this problem because, apparently drug insurers are using Artificial Intelligence (AI) to reject such claims.
They use AI’s algorithms to automatically reject a medical professional’s prescription.
Short, simple English explanation: insurers use their AI predictive tools to deny claims and short-circuit physician review of those claims. They automatically deny thousands of claims at a time for treatments that don’t match certain preset criteria with no actual physician review.
Shorter, simpler explanation: They save lots of money by denying legitimate claims.
It’s the next day. The pharmacy has notified my doc. I notified my doc.
And I’m waiting. Maybe I’ll get an answer before I tee off in The Open at Royal Troon in July.
(I made that up. I won’t be playing The Open. Bad back, you know.)
(Oh, I also made up the part about my powerful golf swing. Just call me AI.)
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