This is a very good article here that talks about what goes on in the back side of a medical practice.   When working with an HMO or PPO contract it can be a very time consuming process. 

Because of all the faxing and paper work that some IPAs require who are not set up on the web, this is one big nightmare, and even then if the initial request is denied, they want additional information faxed!  The physician is unhappy as his medical assistant spends half the time on administrative functions and can’t get in the examining room for enough time when they need to be present with the physician. 

Pharmacies send faxes to remind the physicians on renewals for prescriptions, and shoot that thing runs all day long with faxes from the pharmacies, so between referrals and pharmacy fax bots, the fax machine is the equivalent of the old “water cooler” and there is a worn path back and forth to the machine. From the pharmacy side of this it makes a real good case for e-prescribing and tell the pharmacies to put a stop on the faxes!

Back to the other items at hand, you also have other physicians sending information from one to another, again a case for technology to kick in here too, but the big mess is the referrals and approvals as mentioned here.  I see physicians just pick up the phone and yell at the IPA to get things approved, and that one seems to work pretty well.

If there is anything outside the parameters set forth, be ready for some paperwork and time to accumulate for handling the needs of the patient.  Now let’s add on one other factor here, the physicians get pay for performance on using generic drugs so if a large number patients use the $4.00 prescriptions where it is not tracked by the insurance company, the physician gets dinged for not prescribing enough generic drugs. I did a whole write up on that subject and you can read more here and it was recently featured on Reuters as well.  I’m going to skip EOBs as that is even another lengthy matter that should be discussed on it’s own. 

Does all of this interfere with the quality of healthcare you receive, you bet it does.  BD 

The local pharmacy couldn't get approval from his insurance company to fill my prescription for the painkiller Celebrex. They faxed me a form on which to make my case for the drug.

Completing the detailed form is my penance for trying to give a $120-per-month Celebrex prescription instead of a $4 generic. I support treating patients according to the best scientific evidence, including using standardized protocols that can improve quality and often reduce costs. But I've been this man's doctor for 11 years, and I know his medical needs. Over-the-counter acetaminophen and other arthritis products haven't helped him.

The Doctor's Office -


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