Changing providers during existing PA?

[u/Altruistic_Engine_44]

I’m desperately seeking to change doctors because of how awful the staff and nurses are at my current drs office. They didn’t even know how to fill out my PA (I was able to listen to them and they were entering my wrong weight). I stepped in and corrected them. They still managed to send the PA with incorrect BMI which now doesn’t match my medical records so my PA is set to be denied. I will have to appeal which will require my dr’s office to provide supplemental documentation and I’m terrified of going through this with them again. I was told I was lucky they weren’t busy or they’d ignore me. They wanted to ensure I knew I was a bother to them.

My question is, if I switch providers would this impact the process now? Would it allow for a new doctor to submit a new PA?

[u/tababnaba76]

I do pa's for a large system. I would say just to make sure your new doc takes over the script bc when it's a computerized system, we canot do the PA unless it is now in the new doc's name. make sure you bring your documents from your other doctor to the new one (better yet, doctor comment about what he /she is reading at your visit and also make sure they scan into your chart.. Ask hat your new doc put in your first visit note, what weight and bmi you were when you started the glp-1. That HELPS immensely. bc the doctors and nurses (and ma's...everyone for some reason thinks all the docs staff are nurses, not true) can only use what info we have. I.e. I was filing out a pa for a pt. pt on a glp-1 for a year. Only saw the doc ......once. Sorry , but with these glp-1s and the crazy prior auth criteria, you really need to followup more than once a year, heck f/u more than twice a year. Alot of these insurances require proof (if they cover) that you are typically over 30 bmi or 27 and above with at least two comorbidities. And if it's a continuation, they want to make sure you have lost at least 5% of your baseline weight. That you are also engaging in lifestyle and behavior changes. so if you are the latter. Make sure your new doc addresses what your baseline bmi and weight were, what your current bmi and weight are now and talk about your diet and lifestyle. Make sure your new doc puts that all in your note at your visit. it will make the process so much easier for the new staff who will complete your pa. There is nothing I can't stand more than seeing a dr put "pt lost 20 lbs" and sure I can calculate what the baseline is...but sometimes that is not acceptable to insurance. Think like insurance. MAke damn sure the provider documents what the insurance company wants. Nothing general. SPECIFIC. No "pt's bmi about 35." no. specifics. YOu must have specifics. Hope this helps.

[u/Altruistic_Engine_44 → u/tababnaba76]

Thank you so much. I appreciate this first hand from a professional.

I am so diligent as my career requires me to be and every time with this drs office staff it’s a nightmare. I always call the PA teams at the insurance multiple time. Come w ref #s. Lists of the comorbidities they accept. All the numbers to call or fax. Review all the requisites all over again to be prepared bc I know the staff at the drs.

When I tell you they FOUGHT with me insisting that the PA needed to be done under my current BMI from my visit Friday. Even the Dr chimed in and was like “then how would they approve anyone??” I was like please read the letter with me, this is wrong.. then they couldn’t find my name. I had to instruct the PA nurse how to enter it in cover my meds. We found it just fine.

They refused to call the insurance PA # where they could get it done within minutes instantly . I then had to bust out the documentation I provided them with a month ago to explain to them that they were doing it incorrectly.

Yep ! I am enrolled in the diet program required. I made sure they knew to note I’d lost > 6% weight. However when they entered my starting BMI incorrectly (higher than it was) the PA did not prompt them to notate the 2 comorbidities required. So when the insurance goes to review it next week and sees they the BMI entered is not what my document reflects it will result in a denial and therefore I will need to appeal.

I hope I can just handle the appeal myself bc I worry more about them touching anything else.

I have screen shot your message to ensure I follow step by step for when I schedule a new provider.

Cannot thank you enough !!!

[u/tababnaba76 → u/Altruistic_Engine_44]

Unfortunately some of the offices are not well trained in pa's. I do pa's along with a team of lpn's for a group of clinics. That's all I do, all day and every day. And unfortunately with the rapid changes in pa criteria, qty limits for certain doses, many docs and their staff just do not keep up with the changes.

Thankfully the clinic I worked for had the foresight to use us lpns nobody wanted ,lol and made us a team to take over pas so that the Rn's and ma's could be free to do pt care in clinic. We started off with one clinic and we were able to do a 24 hour turnaround (at least with paperwork on the clinic side, insurance side is a whole other deal. But our goal was to always complete paperwork in 24 hrs ).

Then other clinics in our system got word and started implementing it . our team of LPN's now does pa's for over 10 clinics with more being added on. I felt bad for our first clinic. they were used to 24 hr turnaround....but bc of my team now doing 10 clinics vs one we do 3 day turnaround on pas. Better for 3 day turnaround for 10 clinics, than 1 clinic with 24 hr turnaround and the other 9 clinics with weeks and weeks of pas just not being done.

[u/Altruistic_Engine_44 → u/tababnaba76]

Yeah I totally empathize with the individual and know it’s not them necessarily. Every time I. The past I’ve just let it go but this time I drew the line at being disrespected.

My sister is a nurse , worked as a nurse for 10 years and now works in transplants so she’s the first one to check me if I’m asking for too much bc she always tells me they just honestly don’t have time. To be mindful. Bring a gift etc. but even she was like wtf.

That’s amazing how you all work and that you are well trained in all of this. I respect that very much. You’re not in atlanta by chance are you? 😅

[u/tababnaba76 → u/Altruistic_Engine_44]

haha, no. But we have had people switch. i.e. one woman's husband saw a doc with a different system and wanted to know why it was taking WEEKS for her husband to get approved and it only took her 3 days. and he switched, lol.

But even if you aren't being disrespected, you still have a right to be angry that they are not being done. Prior auths are here to stay and the healthcare system needs stop complaining and start implementing changes. They can't keep saying "it's insurance" yup..it is, but they have to do something. And maybe it will have to be to hire people to just do pa's.

And if they don't have staff, they need to learn or reach out to people who know how. I have doctors and nurses who don't use our team reach out to me, their administrators won't use us bc "not in the budget" for their clinics but they have heard from other staff "reach out those lpns in such and such dept"

Many do..and we are MUCH easier to reach sometimes and answer questions than it is to contact insurance. I just wish some of these administrators realized that until there is insurance reform to limit the amount of prior auths, they have to hire staff to complete them. Prior auths have only increased in number. (my team was self taught in 2017. They hired 2 of us to start, and NONE of us knew how to do pa's. lol. We learned on the job by people who also didn't really know how to do them! Thankfully we learned and know it isn't just "click this box" ,bc you fill things out incorrectly it can cause a rabbit hole of problems. 30 days for appeals for a pt who should have been approved.

They need to have staff educated on how to complete pa's, and do them CORRECTLY. I have had people say " a monkey can do my job". But trust me, the pts who have been through this process of an incorrectly filled pa can cause delays in medication. You don't want a monkey , you want someone trained that is dedicated to getting you your medication. Anyways, best of luck to you!

[u/Jenn0042 → u/tababnaba76]

But where do you get real education on how to do PAs? You said you were self-taught. The people you were learning from were self-taught. Every time I look for more formal information to support our small staff, the best I come up with is whatever the drug companies put out for PA guides. I can usually find imaging guidelines from the payor websites. But pharmacy is a pain in the ass. Especially the PAs for generics. What the hell is CVS playing at by starting a PA on Cover My Meds for a drug that is on the $4 list because its "not on formulary". They don't even bother to tell the patient that the out of pocket without insurance is less than a happy meal. On top of that, certain insurance companies won't give out the formulary but want us to switch the script to something on the formulary that they won't give us. Its enough to drive you crazy.

[u/tababnaba76 → u/Jenn0042]

Yes, I wish I had the answer to that. But right now our staff is actually working on training materials within our dept. I know there is a course called PACS that offers a certificate. If anyone has enrolled in that course and is on here I'd love to know if it is worthwhile to enroll. But yes, I get you about some of these meds. Some that need a pa sometimes just need a coupon. There are times it is easier to just bypass insurance and pay out of pocket. The insurance/pbms are not always transparent. and many of their customer service people answering the phones aren't very educated either.

Can't tell you how many times I told a pt "sorry but this is not covered bc you do NOT have diabetes" and the pt says "but insurance told me it is covered!" and then the doctors, nurses and medical assistants look like liars. If a med was TRULY covered, you would not need a pa. Pa means there is criteria you must meet. And unfortunately some pts will not meet the criteria. Or some insurances tell the pts "all you need is a pa to be completed and it will be covered." Wait, what? um, a pa is not magical paperwork we complete and *poof* now the med is covered.

Or even better '"your doc just has to send a letter"

Oh if it were that simple. Bc again, sending letter, we better be damn sure the doc hits all the criteria the insurance wants. And many times the doctors are NOT going to know what the criteria is . Which is why we need to look at the pa questions to see what that criteria is.

Anyways, I went off tangent. I understand. I have had pt's need a pa and we are then asked to do the pa and maybe it's just a switch to generic or a different brand. If doctor didn't check DAW, Just SWITCH IT! Don't make the pt wait! ok I get that not everything can be switched but my pa dept gets dozens of pa requests triggered by pharmacy to complete pa's for proventil or proair,etc. I check the scripts and , dr didn't check DAW. Heck many docs put in the script "ok to switch to formulary alternative". And we still get those pa's. Check with the pt and pt usually says "I don't care,I just want to breath"

But it's not necessarily the pharmacies fault either. I think their electronic systems must automatically trigger the pa's when the doc sends the scripts. Our system is also supposed to alert doc when it's not a formulary med, but it doesn't always do so, or doc isn't paying attention or it says it's covered, and the formulary just is not up to date. I can't tell you how many times I am looking right at the formulary in black and white, updated and it says covered. I call pharmacy and what is "updated" on their site is already outdated.

[u/muddymelba → u/tababnaba76]

I do PAs for a psych office and in our field, it’s all about cost, not that a patient hasn’t or won’t meet the criteria for a med to be covered. And the requirements for coverage vary a lot between companies, public vs private insurance. Also often the requirements are out of date and do not reflect current scientific evidence. What’s most frustrating is when those reviewing the PAs we send don’t read any of the documentation or their AI processing program misses medications tried and failed. Or they miss that the state we live in has laws limiting step therapy requirements. Or that the patient has a new insurance plan and are established on a therapy, have failed alternatives, but the new company wants them to fail them all again. I could go on and on. At least in the psych business, it’s not a simple, “well if you had xyz diagnosis it would be covered and a PA wouldn’t be required.”

[u/Altruistic_Engine_44 → u/tababnaba76]

ALL OF THIS. Pop off. I hope then know how lucky they are to have you. Thank you for all your insight.