Read the primary source rather than the write-up and the two do not agree, so here is what is actually in it.
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 completion rate deserves as much attention as the headline, because a large effect among those who finished is a different claim from a large effect among those enrolled.
The narrow version of the question is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. I would rather have one careful answer than five confident ones.
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.
This is where I part company with the consensus forming above. 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 BiochemAnswering the narrow version, because the broad one does not have a single answer. The pattern that distinguishes a bad batch from an exit is behaviour rather than product. A bad batch comes with communication, a reshipment offer and a batch number. An exit comes with slower replies, pressure toward less reversible payment methods, sudden discounting, and the same reassurance repeated without any new information. The product tells you less than the correspondence does.
Dr.AddMedPHL said:Agreed, with a caveat about community reputation: it is a lagging indicator.
Mine went the same way, slower. I had assumed I was the exception until I read this.