In reviewing my practice as we’re midway through the year, I have become aware of an increasingly abusive practice of certain “managed care” organizations. They have taken to denying prescription coverage at your pharmacies, for the insurance plan that you paid for, under the guise that the prescription “needs to be reviewed with the doctor and authorized.”

In the good ole days, just because a doctor wrote a script, it was considered good enough.  No physician had to explain himself or herself to an insurance company and “justify” the script. 

Nowadays, insurance companies’ “mangled care” reviewers are inserting themselves in between the doctor, the patient, and the pharmacy. Some of the more outrageous things I’ve been exposed to are:

• A company that suddenly stops paying for something that a patient has been on for years because it stops being a “preferred” medication. Basically, because they can buy something else cheaper which may or may not be as good for the patient – but, hey!  It saves your insurance company money.
• Companies suddenly begin demanding prior authorizations when an adolescent passes 16 years of age (in some cases) or 18 years of age (in others) because ADHD is supposed to just kind of “magically disappear” at particular age thresholds.
• Companies that demand my time to do a PA for something you could print out a GoodRx.com coupon for and get it for $20.00 or less. 
• Companies demand that a physician speak to somebody if a brand-name medication is used instead of a generic. My philosophy on this is simple:
• I always prescribe generic, if it is cheaper, and if I think it will work.  The reason is simple: I try to practice good, economical medical and psychiatric care.  If I can prescribe something cheaper, which works just as well, it keeps EVERYBODY’S cost down, and is my little bit to try to do something about outrageous medical and insurance costs.
• If you or your child is on brand name medication, that’s because we have jointly and collaboratively determined that that is the best medication for you or for him/her.
• It ain’t the insurance company’s job to second guess me on my choices.

Simply because I cannot have my time sucked out of my schedule on a daily basis to explain the basis of my decisions to mangled care companies, I have instituted the following policies:

1. If at all possible, PLEASE do everything you can yourself to get this authorized.  I’ll give you the reason to give them next.
2. If you can’t do it, and if I have to spend time on the phone, or talking with my staff, or writing letters of appeal, I charge $400 per hour, pro-rated for the time it takes me to get the job done. That means that if I spend 15 minutes on hold, or some incompetent insurance clerk burns up 15 minutes of my time, it just cost you $100. Recently, I had the bizarre experience of spending 10 minutes with a clerk who kept putting me on hold and then getting back to me. After 10 minutes, it was determined that I had been given the wrong number by the pharmacy to call and appeal. The number which the clerk then gave me turned out to be a book-making operation. Heaven only knows what the REAL number was supposed to have been.
3. If you call your insurance company up and raise holy-you-know-what with them about how much money is going to be coming out of your pocket for me to deal with these bozos, you might get some action. (Feel free to refer them to this blog entry.) You can also write a letter of complaint, directly to the state insurance commissioners, at the following addresses. Your letter should contain the specifics of why you find the insurance company’s request for prior authorization, or mangled care “review,” unreasonable. Example: You and your kid are on a medication that works, you (or they) have been on it for many years, and now a “PA” is being demanded. That’s ridiculous. The history of the success of that medication is in your/your child’s chart. 

THE ONE EXCEPTION TO THIS POLICY: If I prescribe something “off-label” – which means I’m prescribing it for something which is not described in the PDR or package insert – well, that’s my responsibility. I’ll cheerfully work for your best interests in getting it covered (within reason).

HOWEVER, if I am prescribing any medication for any condition that is covered in the PDR and the “package insert” and is FDA-approved for that indication, then I will charge for begging the insurance company to come through and pay for the medication that you should be entitled to by your insurance policy and your hard earned dollars that you have been contributing, month after month, year after year, for your health care benefits. 

Many of you will no doubt be aware that no other physician has these policies. That is true. Few physicians practice as I do, with clear-headed bookkeeping, accounting procedures, and running their practice as a business. The reason I do it my way is that it is the only way to devote myself exclusively to the relationships I have with the patient, and to literally spoil you rotten with my service and that of my colleagues.

No other practice in the Tri-State offers the following combination of services:

• Free, 24-hour emergency access to the physician by cell phone.  No extra charges. [Try getting in touch with your other doctors on Christmas Eve, New Year’s, or the weekend.]
• A “20 minutes or it’s free” guarantee.
• Relatively generous, free, complimentary access to the physician HIMSELF, by phone, for quick questions that really do need to be answered between appointments.
• An unconditional, no-money-due-unless-satisfied first appointment.
• Limited contact with physician by e-mail.
• The ability to get controlled substances refilled by e-mail if you are due, and via e-scribing.   
• Appointments where you don’t get cranked through the practice like a widget.
• Staff who know you on sight, and where you are a face and a name, not a number or “covered life” in somebody’s “plan.”
• Bullet-proof confidentiality with the Doc Cady, no-bull, “we don’t tell nothin’ to nobody without a signed release of information,” policy.

It may seem as though my policy on “prior authorization” or “managed care review” might be extreme. And it’s possible I may lose some patients over it. That is a sacrifice that I am prepared to make because I refuse to become a pawn in mangled care’s “game” to control the practice of medicine. If enough patients and “covered lives” start bellyaching to insurance commissioners and their state representatives and senators, we darn well might have some change.  The fact that almost every one of my professional colleagues has elected to be cowed by these policies with the notion that, “in order to get along, you gotta go along,” is not my cup of tea. I will not sign on for that type of passive acquiescence to the intrusive, needless, bungling of mangled care organizations and their “reviewers” in the sacred and privileged relationships I have with my patients. 

I hope and trust that I have made both my policies and reasons clear to you. 

The bottom line: I don’t want ANYTHING to come between the relationships I have with my patients. Anything which increases my workload, sucks time out of my schedule, or demands my attention outside of my clinical work with other patients will ultimately jeopardize the level of care and attention I can bring to bear on the patients in my practice. If I make an exception for just “one prior authorization request” I will have to make it for every request. If mangled care continues to tighten the screws – and there’s every indication that they will – it could come to the point that EVERY prescription – other than the absolute cheapest, most common medications like generic antibiotics -  will need a “prior authorization.” That is a road down which I will not travel.

I wish you and your family the very best during the rest of 2024, and I look forward to continuing to give you the kind of service you deserve, have come to enjoy and expect, and hopefully will continue with into the future.

It is, and has always been, a privilege to serve you and/or your child.

Warmly,

Louis B. Cady, M.D.