Every week, sometimes multiple of times a day… I get emails, FB messages, phone calls from chronic pain pts that are being denied care and their medically necessary medication… sometimes from a prescriber, some from a pharmacy/pharmacist, insurance/PBM.
I am about to take on the task of being CFO for the non profit American Pain & Disability Foundation, so there is going to be one more alligator in my swamp…and I am getting tired/bored with giving out the same/similar advise over and over… hopefully after I finish this post they will read it first and/or if they don’t read it first.. I can just answer their question with referring them to this post first with a hyperlink.
FIRST THE PHARMACY/PHARMACIST
I often get some cryptic message about them being denied their medication – and I am suppose to fill in the blanks and come up with a recommendation. Often, I am just replying with the same/similar words that I have routinely typed to other pts.
If the pt is going to a chain store… and you have been getting your meds without problem for months or years and all of sudden they are getting stonewalled.. Most likely, there has been a change in the staffing in the Rx dept of that store or they have encountered a “floating pharmacist” that is working there for a day or week… covering a sick employee, a vacation, a pregnancy leave. Often these Pharmacists don’t know your prescriber, don’t know you and won’t bother to look at your Rx records at the store… JUST SAY NO…
They know that the pt calls HQ, they will be told that they stand behind their pharmacist’s decisions – can’t make a pharmacist to fill a Rx… probably get the same answer from the board of pharmacy. They could ask the Pharmacist to provide the clinical information that they made their decision on… but.. that would create a virtually Tsunami of paperwork.
Another “reason” … “I’m not comfortable”… maybe the pt should ask the pharmacist what clinical information that he/she is not comfortable about ? – IMO “I’m not comfortable” is an EXCUSE not based on few if any FACTS.
Then there is a “we are out of stock”… what the Pharmacist hopes that the pt doesn’t know that the DEA requires that every pharmacy keep a hard copy PERPETUAL INVENTORY… Maybe the pt should document the date/time of being told that the pharmacy is out of stock and send a request to the pharmacy board to ask the pharmacy to provide a copy of the perpetual inventory sheet for the particular medication/strength for the particular day/time… Does the Board of Pharmacy consider LYING TO PTS UNPROFESSIONAL CONDUCT ? If the Board won’t go as far as getting this information – then they apparently don’t.
The pt will probably be told that the Pharmacist has a “corresponding responsibility” which is in the control substance act of 1970… Just have to make sure that the medication is being prescribed for valid medical reason… IMO, corresponding responsibility should be a “two way street” … make sure that medication does not get into the hands of someone that really doesn’t have a valid medical necessity and make sure that the medication gets in the hands of someone that does have a valid medical necessity.. But Pharmacists don’t have access to the pt’s medical records – other than the Rxs they have filled at the store and/or pulled a state PDMP report… Pharmacists don’t have the legal right, nor training, nor physical space, nor time to do a physical exam… If they have not called and talked to the prescriber.. the information that the Pharmacist has is fairly limited… so many use the term “corresponding responsibility” to JUST SAY NO. They turn this term into a ONE WAY STREET TO JUST SAY NO !!!
Other than the state of Alaska, I know of no pharmacists that have experienced any bad consequences for JUST SAYING NO !!
Perhaps, a pt – being denied their medication… share this chart with the Pharmacist… this chart shows the comorbidity complication of under/untreated pain and if a pt is intentionally thrown into cold turkey withdrawal those complications will come on very quickly and probably very intensively… Think hypertensive crisis, stroke, death… how would that affect the pharmacist’s license ?
The quickest path for a pt to get their medication is to find a independent pharmacy … where the pt will be dealing with the Pharmacist/owner who tend to be less judgemental.. here is a website to locate one by zip code https://ncpa.org/pharmacy-locator
DENIAL FROM A PRESCRIBER
More and more prescribers are no longer in a private practice. Their practice has been sold to large hospital system and they are just an employee of that corporation and what they will/won’t prescribe is more likely being dictated by their corporate employer.
It is best if chronic pain pts are proactive when they are first told that they are going to participate in a involuntary forced reduction in their meds. IMO… waiting until you are way down the path of reducing their doses… it is probably too late to back things up Here is a post that I did a few months ago that should give the pt some direction of actions that they may be able to take https://www.pharmaciststeve.com/?p=35002
Insurance/ PBM problems/denials
Many insurance company will hire a PBM ( Prescription Benefit Manager) to handle the adjudication of Rx claims… they provide you the “drug card”. There are a handful of PBM’s that control the lion’s share of the market place.
If your insurance is thru your employer.. abt 50% of large employers are self insured that is referred to as an ERISA prgm – over seen by the Fed Labor Dept and insurance company is just an administrator to pay out your employer’s money for health claims for their employees and their families. If you have this sort of “insurance” and you get denied…someone at your employer can just call up the insurance company and tell them to pay for your medications as your prescriber wrote for… after all it is your employer’s money that they are paying out.
If you are on Medicare or Medicaid… then you are probably dealing with a Part D Rx prgm… they have a three level appeal process.. they don’t have to tell you about the process unless you ask and then they have to give you the process in writing- today that is probably a website. Be sure to meet the time limits of making the appeals… expect to get denied the first time because the same system/people that already denied it … is the one handling the appeal.. because a fair percent of pts getting denied will give up… after three denials there is a Administrative Law Judge (ALJ) again they have to tell you the process is writing… the very fact that you KNOW ABOUT the ALJ appeal level… may be enough to get them to cave… because they know that at least 50% get to this level will get approved. Doesn’t cost the pt anything, and now a days… it is probably a ZOOM type meeting.. the pt doesn’t need an attorney… just needs to state way they need what was denied … it is a pretty straight forward process.
It is also good if the pt calls 800-MEDICARE or www.cms.gov and file a complaint against any provider for denying you care.
Any other kind of health insurance… you just have to ask what their appeal process is and if they don’t offer… ask for the details in writing… the more times you appeal … the more likely the pt will get a YES/APPROVED.
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In this presentation, Dr Lembke made the statement that “doctors are limited in what they can fix… “once it is broken ” after she stated earlier in the video stated that the “body can heal itself ” So the question has to be asked and answered… if the body can’t heal itself and the doctor’s skill set can’t fix it… what is a pt to do… particularly if some intensity of pain is the result of this “catch 22″… ? Accept taking some opiate therapy and try to optimize their QOL , become home, bed. chair confined and JUST SUFFER… or commit suicide or opt for a “death with dignity” process in those states that allow this.
