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Bupe Prior Auths

posted Jan 1, 2014, 3:52 PM by PC/SM Chief Resident

From Chinazo: 


Just to keep everyone in the loop, at our bupe case conference this week, Lola Poku joined the meeting, so we focused on the bupe PA process. In general, the process has continued to improve over the last several months, but there were a few areas that still needed clarification and/or improvement.

 

1. Once a PA is obtained, Lola is creating a flag that is a reminder about the expiration date. The flag is sent about a month prior to the PA expiration date to  herself, Angela, and the doctor. This process is in place so that we can proactively obtain the PA rather than reactively obtain the PA, in which case the patient may run out of medication due to delays. When the PA is being renewed, there is no need to take any additional action. Lola looks at the prior PA note and basically copies that information. Angela will briefly review these flags to make sure there have been no changes since the time the prior PA was approved. If changes have been made, Angela will communicate that to Lola. If the doctor knows that changes have been made, please communicate this to Lola as well (e.g., if the patient is no longer in care, let Lola know so she doesnt renew the bupe PA).

 

2. Most of the time the doctors provide Lola with all the necessary information to obtain the PA. However, sometimes, some information is missing. This information tends to be about whether another treatment was tried before the current treatment, and if so, for how long and what was the outcome. While this question has relevance for many other meds that may require PA (e.g. before prescribing lyrica, was neurontin prescribed?), for opioid dependence, our only treatment option is buprenoprhine. So, we decided that the answer to that question (whether another treatment was tried before the current treatment) would be "no" for all patients. We felt prior methadone is not so relevant, because we cannot prescribe that medication for opioid dependence. I have changed my quick text to include that information (with the new text italicized). So....my revised quick test for ".pa" is:

 

Diagnosis = opioid dependence, ICD9=304.00

Has been receiving suboxone treatment x 1 year

Currently in treatment program

meds: suboxone 8/2mg 1.5 SL bid, dispense #90 per month

tabs or film is fine, generic is fine

Has not tried a different treatment previously because buprenorphine is the only option for treatment of opioid dependence outside of a specialized drug treatment program.

My DEA/SAMHSA number is XC5942215

 

Please feel free to copy this and make it a quick text for you as well.

 

3. When Lola is out, Ray covers her and the PAs. However, Ray still has his normal duties as well. Because of this, we decided that it makes sense for Ray to address only the urgent bupe PAs, and not the routine PAs that are about to expire, but not yet expired. In addition, at times, it may be difficult to know that Ray is covering for Lola, as it appears as though the phone note is coming from Lola, but the signed note/action within the phone note is coming from Ray. This is something we probably just need to pay better attention to.

 

4. The process regarding more complicated PAs is as follows:

 - Using the information sent to Lola, she  fills out the insurance form and uses the doctors' stamps to "sign" the form and faxes it to the insurance company. Depending on the company, she may also print out and fax the utox test results.

 - The insurance company tends to get back to Lola within 24-72 hours for a PA decision

 - If Lola does not hear from the insurance company by 72 hours, she contacts the company to follow up

 - If there are additional issues that need to be addressed, Lola will call the doctors on their cell phone or overhead page them in the clinic. We agreed that this should happen if after 72 hours no PA has been obtained due to unresolved issues or unanswered questions that need to be addressed/answered by the doctors.

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