Second Opinions: Englewood Family Health Center

May 22, 2009

The challenge: Health plans deny or require pre-authorization for prescriptions of name-brand drugs.

ENGLEWOOD FAMILY HEALTH CENTER ENGLEWOOD, NEW JERSEY

THE CHALLENGE:

Latorre estimates that for every denial, he and his staff spend more than an hour haggling with insurers and completing paperwork, not to mention fielding calls from angry patients who wonder why they can't obtain the medicine their doctor says they need. Each denial ends up costing him about $95 in time and phone bills, he says.

Latorre sometimes provides samples that he gets from pharmaceutical reps, but those only go so far. In the meantime, he's been prescribing only generics, which leaves him unsatisfied.

"I feel I am not really giving the best of my work to my patients," he says.

THE SOLUTION:

There's no easy solution when a doctor tries to challenge the protocols insurers have developed, warns David C. Scroggins, CHBC, a practice management consultant with Clayton L. Scroggins Associates in Cincinnati, Ohio.

Latorre and similarly vexed doctors can try to appeal insurers' denials, but that's time-consuming and counterproductive, Scroggins says, so doctors should carefully consider which cases are worth fighting and pursue only a select few.

Latorre's best bet-for reducing patients' ire at his practice, at least-may lie in getting patients to understand why the drugs he thinks are best for them are getting denied. Perhaps that will open patients' eyes and inspire them to seek out more comprehensive insurance, Scroggins says.

"Remember, the patients are the ones who have purchased their health insurance policies, and this experience will give them insight into the quality of their policies, so perhaps they will upgrade in the future."

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