INDIANA HEALTH GROUP FREQUENTLY ASKED QUESTIONS (FAQ)
INFORMATION FOR PATIENTS REGARDING MEDICATION/TREATMENT PRIOR AUTHORIZATION Recently, you were given a prescription for a medication that, based on your insurance company's policy, requires a prior authorization. A prior authorization means that your company is asking for additional information or justification for the use of the medication that was prescribed for you. A prior authorization is typically required for medications that are newer or more expensive than generic medications or less expensive medications covered by your health plan. Requests for prior authorizations are usually initiated by the pharmacy when you attempt to fill a prescription. Typically, your insurance company will contact us by fax in order to request more information. Our office has staff members that deal with this on a daily basis. This is a very labor-intensive process that typically requires of review of your records, information on your current diagnoses, current medications, previous medications you have tried, other medical problems you have, and symptoms you are experiencing. Once we collect this information, we immediately send it to your insurance company or their representative handling the prescription benefit for their review. Our office handles the prior authorization request as efficiently as possible, however, there are often delays in this process. Often times, insurance companies claim we have not responded to their requests for information. We have found that this is virtually never the case as we typically have documentation that this information was sent to the appropriate person in a timely fashion. There are sometimes delays of days or weeks for the company to make a determination regarding their willingness to cover the prescribed treatment. While our office does everything in it's power to facilitate this process, it is ultimately up to the insurance company to decide whether or not the medication will be covered under your insurance benefit. We cannot compel them to do so, even when we strongly feel that a certain medication has specific advantages over another to provide you with the highest level of care. We would strongly recommend that you take an active role in this process. Insurance companies are usually more responsive to patients and employers than they are to physician offices or to physicians. If you are dissatisfied with the coverage you have for the prescribed medication, we would strongly encourage you to contact them yourself and to speak with the human resources office of the insured party's employer to make them aware of these frustrations as they may also be able to advocate for you. We hope that this information is helpful and provides a greater understanding of the processes involved in obtaining prior authorizations. Please feel free to contact us for further questions. Sample Letter Sent To Insurance Company Regarding Denial Of Requested Medication: Recently, my patient < > and I were notified of your decision to deny coverage for ______ . This treatment recommendation was based on the patient's symptoms, previous history, and past medication failures. This medical decision was reached based on my knowledge as a licensed physician practicing in the state of Indiana, an understanding of both FDA approved indications as well as the information available in peer-reviewed medical literature supportive of the use of this treatment in this manner. Addtionally, this decision was based on my personal expertise and experience in treating patients suffering from this and similar medical conditions. A copy of this letter will be sent to my patient and included in the patient's file so that they may understand that (1) the decision to deny coverage was solely that of the benefit administrator and their representatives, (2) this denial constitutes an obstacle to my ability to treat my patient optimally and to the best of my abilities, and (3) that my office is making every reasonable effort to obtain authorization for coverage of this treatment. My patients are also encouraged to take a proactive role in the responsibility for their healthcare by sharing their concerns regarding denial of coverage directly with the plan administrator/customer service department and with those persons responsible for selecting their healthcare plans at their place of employment. I am hopeful that my patient will, as I do, understand that there exists a very real need to provide cost-effective medical care including cost containment procedures, utilization management, and a reasonable degree of oversight of the provision of medical services and treatments. However, I believe that it is important that the patient be made aware that one of the primary considerations in authorization or denial of coverage is the cost of the recommended treatment. I believe that it is important that the patient be made aware of the potential risks and benefits of other treatment options suggested as alternatives by the benefit administrator (as we would for all recommended treatments). I believe that it is important for patients to understand that most generic medications are safe, effective, and considerably less expensive alternatives to their specific brand name counterparts. Patients should also understand that generic medications are not necessarily identical to their brand name counterparts as the law permits a certain degree of difference in terms of how the medication is absorbed by, acts on, and is eliminated from the body. It is also important that they understand that a request by the benefit administrator to change to a generic medication of a different pharmacologic class is inappropriate and ill-advised. My patient and I understand that your decision to deny coverage for what I, as the patient's physician, consider to be a medically necessary treatment does not preclude the patient from obtaining this medication outside of their healthcare benefit plan. Often, such denials include recommendations for alternative forms of treatment which could be construed as the practice of medicine under Indiana Code IC25-22.5-1-1.1, section 1.1a1B (see below). Please let this letter serve as a formal request for an external appeal or peer to peer review of this denial. Please be advised that in as much as I am a board-certifed psychiatrist licensed to practice in the state of Indiana, I am requesting that a peer to peer review be conducted with another board-certified psychiatrist licensed to practice in the state of Indiana. Below, please find some pertinent history regarding the past treatment of < >. Sincerely,
Indiana Health Group
INDIANA CODE – DEFINITION OF THE PRACTICE OF MEDICINE IC 25-22.5-1-1.1
Sec. 1.1. As used in this article:
(a) "Practice of medicine or osteopathic medicine" means any one (1) or a combination of the following:
(1) Holding oneself out to the public as being engaged in:
(A) the diagnosis, treatment, correction, or prevention of any disease, ailment, defect, injury, infirmity, deformity, pain, or other condition of human beings;
(B) the suggestion, recommendation, or prescription or administration of any form of treatment, without limitation;
(C) the performing of any kind of surgical operation upon a human being, including tattooing, except for tattooing (as defined in IC 35-42-2-7), in which human tissue is cut, burned, or vaporized by the use of any mechanical means, laser, or ionizing radiation, or the penetration of the skin or body orifice by any means, for the intended palliation, relief, or cure; or
(D) the prevention of any physical, mental, or functional ailment or defect of any person.
(2) The maintenance of an office or a place of business for the reception, examination, or treatment of persons suffering from disease, ailment, defect, injury, infirmity, deformity, pain, or other conditions of body or mind.
(3) Attaching the designation "doctor of medicine", "M.D.", "doctor of osteopathy", "D.O.", "osteopathic medical physician", "physician", "surgeon", or "physician and surgeon", either alone or in connection with other words, or any other words or abbreviations to a name, indicating or inducing others to believe that the person is engaged in the practice of medicine or osteopathic medicine (as defined in this section).
(4) Providing diagnostic or treatment services to a person in Indiana when the diagnostic or treatment services:
(A) are transmitted through electronic communications; and
(B) are on a regular, routine, and non-episodic basis or under an oral or written agreement to regularly provide medical services.
In addition to the exceptions described in section 2 of this chapter, a nonresident physician who is located outside Indiana does not practice medicine or osteopathy in Indiana by providing a second opinion to a licensee or diagnostic or treatment services to a patient in Indiana following medical care originally provided to the patient while outside Indiana.
(b) "Board" refers to the medical licensing board of Indiana.
(c) "Diagnose or diagnosis" means to examine a patient, parts of a patient's body, substances taken or removed from a patient's body, or materials produced by a patient's body to determine the source or nature of a disease or other physical or mental condition, or to hold oneself out or represent that a person is a physician and is so examining a patient. It is not necessary that the examination be made in the presence of the patient; it may be made on information supplied either directly or indirectly by the patient.
(d) "Drug or medicine" means any medicine, compound, or chemical or biological preparation intended for internal or external use of humans, and all substances intended to be used for the diagnosis, cure, mitigation, or prevention of diseases or abnormalities of humans, which are recognized in the latest editions published of the United States Pharmacopoeia or National Formulary, or otherwise established as a drug or medicine.
(e) "Licensee" means any individual holding a valid unlimited license issued by the board under this article.
(f) "Prescribe or prescription" means to direct, order, or designate the use of or manner of using a drug, medicine, or treatment, by spoken or written words or other means.
(g) "Physician" means any person who holds the degree of doctor of medicine or doctor of osteopathy or its equivalent and who holds a valid unlimited license to practice medicine or osteopathic medicine in Indiana.
(h) "Medical school" means a nationally accredited college of medicine or of osteopathic medicine approved by the board.
(i) "Physician's assistant" means an individual who:
(1) is an employee of a physician;
(2) is a graduate of a physician's assistant training program approved by the board;
(3) has successfully completed the national examination administered by the national commission on the certification of physician's assistants; and
(4) has registered with the board.
(j) "Agency" refers to the Indiana professional licensing agency under IC 25-1-5.
As added by Acts 1978, P.L.8, SEC.13. Amended by Acts 1981, P.L.222, SEC.151; P.L.247-1985, SEC.1; P.L.169-1985, SEC.62; P.L.217-1993, SEC.2; P.L.180-1996, SEC.1; P.L.181-1997, SEC.1; P.L.1-2006, SEC.444.
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"I received a letter from my insurance asking me to change my medication, should I do this?"Sometimes companies will contact you in order to offer you the ability to cahnge to a generic version of your medication. Much of the time, this may be appropriate. However, we have seen an increasing trend of companies attempting to change a patient's medication to a completely different medication while making it appear that they are offering a generic version of the same medication. Please contact our office for questions on this and see the sample letter below that we send out to patients and insurance companies when we find this is happening: Dear Patient, Recently, our office received a communication from your pharmacy benefit company _______________ requesting that we change your current medication ________________ to the "preferred alternative" medication ________________. You may have received a similar communication by mail from the company regarding this issue asking you to speak with your physician regarding the use of a "cost saving alternative" WE ARE SENDING YOU THIS LETTER BECAUSE WE BELIEVE THAT THIS PRACTICE IS MISLEADING AND DECEPTIVE. YOUR PHARMACY BENEFIT COMPANY IS ATTEMPTING TO CHANGE YOUR MEDICATION! THIS IS NOT A GENERIC VERSION OF YOUR PRESCRIBED MEDICATION. THIS IS A COMPLETELY DIFFERENT MEDICATION. We are not opposed to the use of appropriate and safe generic medications when they are available. However, we are strongly opposed to outside parties attempting to change your medication regimen in what appears to us to be a very deceiptful manner. We have contacted your company in the past to express our concerns over this inappropriate intrusion into your healthcare, however, they have chosen to ignore our concerns and our repeated requests for them to stop this practice. You may want to contact the benefit administrator at the place of employment through which your insurance is provided to make them aware of your dissatisfaction with this policy. If you have concerns about the appropriateness of this policy, you may also wish to contact the Indiana Department of Insurance at 311 West Washington Street, Suite 300 Indianapolis, IN 46204-2787 phone number 317-232-3520. ----------------------------------------------------------------------------------------------------------------------------------- PRIVACY
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Inspect and Copy health information that may be used to make decisions about your care. You have the right to inspect and copy your Protected Health Information. To exercise this right, you must submit your request, in writing, to IHG. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy under limited circumstances. If we deny you access to your PHI, you may in some cases request review of the denial. IHG will choose a licensed healthcare professional (who did not take part in denying your request) to review your request and the denial. We will comply with the outcome of the review.
Right to a Paper Copy of all authorizations for use and disclosure of PHI for which the individual served is asked to sign by IHG. A paper copy of all such requests shall be provided to the individual served.
To Request to Amend health information we have about you if you feel that it is incorrect or incomplete. You have a right to request an amendment for as long as the information is kept by or for IHG. To request an amendment, your request must be made in writing and submitted to IHG. In addition, you must provide a reason that supports your request.
- We may deny your request for an amendment if it is not in writing or does not include the reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
-Is not a part of the health information kept by or for Indiana Health Group.
- Is accurate and complete.
To an Accounting of Disclosures. This is a list of the disclosures we made of health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Indiana Health Group. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs for providing list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before the cost are incurred.
To Request Restrictions on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the heath information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Indiana Health Group. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have a right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Indiana Health Group. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
To a Paper Copy of This Notice You have a right to a paper copy of this notice. You may request a copy of this notice at any time.
COMPLAINTS
I f you believe your privacy rights have been violated, you may file a complaint with Indiana Health Group or with the Secretary of the Department of Health and Human Services. To file a complaint with IHG contact the group administrator at 317-843-9922. You will not be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your writ ten permission. I f you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. I f you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your writ ten authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each of our locations.
----------------------------------------------------------------------------------------------------------------------------------- What is a Psychiatrist?
A psychiatrist is a medical physician who specializes in the diagnosis, treatment, and prevention of mental illnesses, including substance abuse and addiction. Psychiatrists are uniquely qualified to assess both the mental and physical aspects of psychological disturbance. Their medical education has given them a full working knowledge of the many causes for a patient’s feelings and symptoms. Armed with this understanding, psychiatrists can make a complete, accurate diagnosis and then recommend or provide treatment. What is a Psychologist?
Most clinical psychologists have a master's or doctoral degree; on the doctoral level, the degree is usually a Ph.D. (doctor of philosophy) or Psy.D. (doctor of psychology, which is not a medical doctor). A psychologist applies psychological principles to the treatment of mental, emotional, and behavioral disorders and developmental disabilities through a broad range of psychotherapies. A psychologist is commonly trained in advanced psychology, abnormal psychology, statistics, testing theory, psychological testing, psychological theory, research methods, psychotherapeutic techniques, and psychosocial evaluation. What is a Licensed Clinical Social Worker?
A licensed clinical social worker (L.C.S.W.) is also trained in psychotherapy and helps individuals deal effectively with a variety of mental health and daily living problems to improve overall functioning. A social worker usually has a master's degree in social work (M.S.W.). and has studied, among others, sociology, growth and development, mental health theory and practice, human behavior/social environment, psychology, research methods. What is an Advanced Practice Psychiatric nurse?
An advanced practice nurse is typically either a Clinical Nurse Specialist or Nurse Practitioner. A psychiatric nurse may have an associate arts, bachelor's, or master's degree in nursing. Much of the psychiatric nurse's specialty training takes place in a hospital inpatient service. Among the services the psychiatric nurse is trained to provide (at the order of a medical doctor) are various patient care services, administration of medication, and other duties commonly performed by nurses, such as immunizations and skin tests. What is a Physician Assistant?
Physician assistants are health care professionals licensed, or in the case of those employed by the federal government they are credentialed, to practice medicine with physician supervision. As part of their comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and write prescriptions. Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. A PA's practice may also include education, research, and administrative services. ------------------------------------------------------------------------------------------------------------------------------------------------ |
