Community Forum

First Letter (09February2008)

The first sample letter is posted. It's a simple prior authorization request that states that the requested medication is medically necessary and explains why the insurance company doesn't need all the details they usually ask for unless they intend to engage in medical decision making. I have had good success with letters of this general form in the past.

The letter does have some verbiage that is unique to California, but that can easily be edited (you can copy and paste the text, or a downloadable file is available to allow you to customize the letter in your favorite word processor). Right now I'm working on the database of fax numbers for requests, as well as some pages to which plan administrators can be referred if they don't understand what medical decision making is, why they're not legally permitted to do it, why you can't just willy-nilly substitute one drug for another after a patient visit is over, etc.

The procedure for registering for the site is still a bit rough. I'm working on it. In the mean time, feel free to browse.

-- RonRisley - 10 Feb 2008

Welcome (30January2008)

Welcome to the prototype web site for PriorAuthRx.com.

Of the many ways our health care system is broken, the system for "controlling prescription drug costs" seems to be among the most emblematic. Insurers have a legitimate interest in controlling costs, so they devise formularies that list preferred drugs. Great, but the process of creating formularies has been corrupted by drug company money (see "Straight Talk About Formularies? .") In addition, the proliferation and fragmentation of insurance and prescription drug benefit plans make it nearly impossible for providers to get accurate information at the moment a prescribing decision has to be made (most of the time, even the patients don't know what their drug plan is).

The system isn't working for anybody. Patients are suffering because they're not getting their medications in a timely fashion or are paying more than is necessary. Doctors and nurses are spending time filling out forms instead of taking care of patients. Insurers are having to face frustrated pharmacists and providers, angry or unnecessarily sickened patients, and a mountain of paperwork. I think we can do better.

This site will initially focus on the needs of providers, mostly because I am one and so that's the part of the problem I'm most interested in.

• In the next few days, I hope to have some sample prior authorization request letters. These can be downloaded and modified to suit your practice. They focus on sending the insurer information that is appropriate to their approval process while avoiding requiring a lot of information relevant only to medical decision making (which insurers are forbidden by law from doing).

• I have started a database of insurance plans and their fax numbers, so providers will have a single source of information on where to send prior authorization requests and, if necessary, appeals. Much of that information should be available over the next few weeks.

• In the coming months, I hope to get the actual formularies database running. Insurers who wish to assist providers and consumers in selecting formulary-listed medications will be able to list their formularies in a central, easy-to-use format at no cost.

• I am planning a completely automated prior authorization submission and tracking system. Enter your request in a simple on-line form, and it will be faxed directly to the insurer. Responses will be collected, tallied, and tracked, and appeals to regulatory agencies generated when necessary -- all in a secure, easy-to-use environment.

• Once the system achieves critical mass, I can start posting information of use to consumers: who makes their formularies available here, and how timely they are about approving medically-necessary non-formulary medications.

The business model, if any, is still up in the air. I am fortunate to have my own secure server farm and can do my own programming. I am not planning on charging for any of the services though if the idea really takes off (and thus becomes expensive to operate) I might consider accepting advertising to offset costs.

You can monitor progress here via an RSS newsfeed, or you can sign up and elect to receive notification by email when the site changes, or just bookmark this page and visit periodically.

As a potential user of this service, your ideas and feedback are vital. Please feel free to sign up and comment, or email me directly. And above all...

Be well...

-- RonRisley - 30 Jan 2008