Surely there is a 12 paragraph article somewhere you could post explaining PDP's and their PA rules? Thought everyone already knew alot of drugs have PA.
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KFF Report on MAPD Prior Authorization
- Thread starter somarco
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Surely there is a 12 paragraph article somewhere you could post explaining PDP's and their PA rules? Thought everyone already knew alot of drugs have PA.
Why would I need to do that?
One of our elite members seems like he needs a lesson and that seems to be easiest way to teach it.
Don't get it confused, PA for medication is wildly different than getting a PA for medical procedures. While both require the doctor to submit information, the process for approval is quite different. Anyone who acts as if PA is a non-issue on MAPD plans has their head buried in the sand. This member yo are referring to recently emailed me information about both Aetna and Humana using a third party to handle their vision benefits and the initial response for cataract surgery is an auto decline in Georgia and Florida. That's their standard operating procedure. It's an issue MAPD members have to navigate. If the member were required to handle it versus the doctors office handling it, I'm willing to bet MAPD plans would get more complaints and lower ratings.
Like I mentioned elsewhere the best thing OM could do is require PA. There is a reason Med Sup premiums increase dramatically over time. It's a free for all for the Drs, Nursing facilities, etc. Why do you think all the Drs and Nursing homes tell clients to stay away from MAPD's? They don't want anything questioned or to have to do a little more work getting PA. I just tell clients to ask them if they are going to pay their premiums for the Med Sups and PDP. So far none have offered.
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I wonder if the Med Sup UW would be less stringent if they knew OM was going to make sure everything being done is medically necessary. Honest question. I do feel bad for Med Sup companies bc they have no say in what claims they pay.
I always think back to when my Mother was in a nursing home with Alzheimers and they came daily to run each one of them through either physical, speech or occupational therapy and most were still sleeping when they came back. I can't even fathom how much is spent on this nationwide a year. I put a stop to my Mothers quickly. Put play doh on her lap and if she happened to wake up she would just look at it.
T Sparks
Super Genius
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Only in your dreams!
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From CMS . . .
An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.
Authorization mentioned once on this page . . . exception mentioned 15 times. Sorry for the confusion . . . .
Prior authorization starts the process for the expected end result . . . a formulary exception.
An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.
- A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
- A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug.
Authorization mentioned once on this page . . . exception mentioned 15 times. Sorry for the confusion . . . .
Prior authorization starts the process for the expected end result . . . a formulary exception.
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Medicare Advantage Growth Exacerbates Prior Authorization Burdens:
MGMA surveyed over 600 medical groups in March 2023 to further understand the impact of prior authorization in the Medicare Advantage program.
The majority of practices (95 percent) provide care to patients covered by Medicare Advantage, and 75 percent report they are seeing an increasing number of these patients. Compared to commercial plans, traditional Medicare, and Medicaid, practices said Medicare Advantage was the most burdensome when it came to obtaining prior authorization.
https://revcycleintelligence.com/ne...rowth-exacerbates-prior-authorization-burdens.
MGMA surveyed over 600 medical groups in March 2023 to further understand the impact of prior authorization in the Medicare Advantage program.
The majority of practices (95 percent) provide care to patients covered by Medicare Advantage, and 75 percent report they are seeing an increasing number of these patients. Compared to commercial plans, traditional Medicare, and Medicaid, practices said Medicare Advantage was the most burdensome when it came to obtaining prior authorization.
https://revcycleintelligence.com/ne...rowth-exacerbates-prior-authorization-burdens.
