Putting this up for argument rather than for agreement. I have read it twice and I am still not certain what it supports.
Denials are usually procedural rather than clinical, and the order that works reflects that. Get the denial reason in writing, because it names the criterion you failed. Then supply the documentation that criterion asks for — usually documented BMI with a comorbidity, or a failed prior therapy. Then appeal, and ask for a peer-to-peer review, because a prescriber talking to a reviewing clinician resolves a large fraction of denials that written appeals do not. Manufacturer copay assistance is separate and applies mainly to commercial insurance, and patient assistance programmes are means-tested rather than a discount.
Where I think it is weakest: the comparator does most of the work in how this gets reported, and it is not the comparator most people think they are citing.
What I am after is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. Not looking for reassurance. Looking for the part I have got wrong.
tane_welly said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Agreed, with a caveat about community reputation: it is a lagging indicator. Reports arrive weeks after orders, so a supplier can look excellent for a month after quality has already changed.
tane_welly said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Filing a mild objection. Mild because I might be wrong; an objection because nobody has addressed the case that does not fit. The affordability discussion here usually stops at individual tactics. At list price this class is out of reach for most of the people who would benefit, and no amount of appeal strategy changes that — it is a pricing problem wearing a paperwork costume.
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Browse GL BiochemThis one has a reasonably settled answer, so here it is. Prices dramatically below market are the strongest single signal, and the reason is arithmetic rather than suspicion. Synthesis, testing, and cold-chain shipping have floors. A price well under the floor means something was skipped, and the two things that get skipped are testing and content.
amsterdam_pete said:Agreed, with a caveat about community reputation: it is a lagging indicator.
Second this. I had assumed I was the exception until I read this.