Patently Absurd Passive Aggressive Prior Authorization Approval

Posted By: Eric A Kropp MD President's Blog,

In my solo practice, I complete the medication prior authorizations, and frankly, sometimes the indignation gets the better of me and my contrarian tendencies emerge. The following are all actual responses that have been submitted. Some are humorous, some obnoxious, and some completely nonsensical, yet they ALL resulted in approval. What exactly does that say about this ridiculous process? You be the judge.

Most PA’s start with a seemingly innocuous request for a diagnostic code. But when they require it to re-authorize a medication that they are already paying for, I remind them.

"It's the same as last time. Go look it up."

Or simply, "Seriously?”

Who knows, maybe there actually is an ICD-10 code for disbelief. 

If they try to drown me by requiring minutia of past therapeutic trials, I diligently fill in all the fields.

They asked: | Drug Name| Strength | Dosing Schedule | Date Prescribed | Date Stopped | Description of AE or failure |” and I responded: " | You can look this up | he has filled | numerous | medications | through | you"

Other forms just give you three boxes with which to work. Easy. " | Of course | He has | tried others |"

Perhaps next time I shall respond in Haiku.

Once I answered by pounding on the keyboard cathartically:

What previous dose has your patient tried?: "il8duy,kutsmmtmmsy"

What is your current treatment plan?:  "q46jw56sjyr"

What is the diagnosis related to use?: "rshtdny"

Please provide clinical support for requesting this dose and quantity.: "rjwnyswyjnsrwyh"

Another time, a stream of consciousness ramble highlighted the insanity of needing to provide yearly justification for a stable medication of 3+ years.

“[Two 20mg XR capsules are] the most effective way to administer a 40mg XR dose, although mathematically, he could take two 15 mg capsules along with a 10 mg capsule. or four 10mg capsules. or eight 5 mg capsules. or two 5 mg capsules, and three 10mg capsules. or maybe two 5 mg capsules, one 20 mg capsule and one 10mg capsule. or you could just take it face value that the patient is being prescribed the most appropriate dosing regimen and pay for this covered benefit, and leave the rest to me. or you could read the prior auth from LAST YEAR WHEN HE WAS ON THE EXACT SAME THING!"

If being obstinate would jeopardize the patient's wellbeing, however, I do walk the line between actually providing information, and expressing my indignation. So when a prescription for hydrocodone for cancer pain required a third prior authorization for the third prescription, my patient and I were both fuming. He was very supportive of me submitting the following explanation:

"He has cancer. It's really big. The size of a fist. And it's in his rectum. And it is still growing. So he needs this medication to help with the pain of the growing fistful of invasive cancer in his rectum while we try to kill his cancer. Clear enough rationale?"

But pushback need not be rude. My personal favorite approach to satisfying the PA algorithm while still getting in a dig or even a laugh is to selectively attach creative additional documentation. It can be as simple as a PDF that says "This page intentionally left blank,” or if I am feeling cheeky, I might send a cute cat picture. One time I attached patient instructions for neck stretches to release the tension from staring at a computer screen. Because I am sure that if there is actually a human on the receiving end of these prior authorizations, it must be an uncomfortable experience.

Clearly these real examples that received approval demonstrate that the prior authorization process is a farce. It is predicated on distorted values that believe it is acceptable to burden clinicians and their staff to provide justification for routine medical therapy. The reality is that they exist so every middleman inserted between the patient and their physician gets paid for their job, however superfluous or unconscionable it may be.

I hope to hear many complaints from insurers and their complicit profiteers about a rash of cat pictures being sent as supporting documents in the near future!


Eric Kropp, MD
NHMS President