Can someone help with this doctor and prior authorization snafu?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

It will, so you should start the process of switching doctors now.

And, how do I find a doctor who will do appeals? Is it a new Rx with a new doctor or an appeal? All of these questions are exhausting me.

[Anonymous]

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

Ok, this is a different situation than the office (I'm assuming the doctor doesn't submit these herself) refusing to submit the way the insurance is asking.

No advice, assuming that was clearly stated at the time you became her patient. If it wasn't, then you can point to that and say "no appeals" is a new policy that you should not be harmed by.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

It will, so you should start the process of switching doctors now.

And, how do I find a doctor who will do appeals? Is it a new Rx with a new doctor or an appeal? All of these questions are exhausting me.

From what you've described, you don't have an appealable issue. Your doctor never submitted correct paperwork.

But an office that refuses to do appeals should be a red flag. You'll have to call up difference offices and ask them.

[Anonymous]

Anonymous wrote:

Anonymous wrote:It is a continuation of Rx. It is initial request under this plan. I can see why your doctor won’t say it’s an initial prescription because that contradicts your medical records.

I called the insurance directly and they said it should be initial. Continuation only applies if you have reached maintenance dose, and I have not. I have only been on it for 3 months.

That sounds like a plan specific definition. I’d be asking for that in writing because the definition clearly is not how your previous plan used that terminology and not how your doctor understands the terminology. And as someone who litigated a lot of insurance denials, it’s not a definition that is intuitive to me but plans are allowed to have their own definitions.

It is odd to me that a doctor in network who provides this treatment doesn’t know the terminology. No judgement about the doctor. Just seems like a communication breakdown or even an insurance processing issue.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:It is a continuation of Rx. It is initial request under this plan. I can see why your doctor won’t say it’s an initial prescription because that contradicts your medical records.

I called the insurance directly and they said it should be initial. Continuation only applies if you have reached maintenance dose, and I have not. I have only been on it for 3 months.

That sounds like a plan specific definition. I’d be asking for that in writing because the definition clearly is not how your previous plan used that terminology and not how your doctor understands the terminology. And as someone who litigated a lot of insurance denials, it’s not a definition that is intuitive to me but plans are allowed to have their own definitions.

It is odd to me that a doctor in network who provides this treatment doesn’t know the terminology. No judgement about the doctor. Just seems like a communication breakdown or even an insurance processing issue.

Lots of doctors don't care anymore. They'll cram more patients in their schedule and do the bare minimum.

[Anonymous]

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

None of the foregoing is relevant to the suggested action, which is for you to prepare yourself what you want submitted, along with gathering the necessary supporting data to submit with it, then meeting the doctor to get it signed/submitted.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

None of the foregoing is relevant to the suggested action, which is for you to prepare yourself what you want submitted, along with gathering the necessary supporting data to submit with it, then meeting the doctor to get it signed/submitted.

The doctor isn't willing to sign and submit it, though. Would a bribe help? What would be a reasonable amount?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

It will, so you should start the process of switching doctors now.

And, how do I find a doctor who will do appeals? Is it a new Rx with a new doctor or an appeal? All of these questions are exhausting me.

From what you've described, you don't have an appealable issue. Your doctor never submitted correct paperwork.

But an office that refuses to do appeals should be a red flag. You'll have to call up difference offices and ask them.

Right? It didn’t sound like an appeal but rather a re-submit?

[Anonymous]

There’s a surface called callondoc that a lot of people who use that bound speak highly of. I have not used it because my plans specifically excludes weight loss drugs

[Anonymous]

Anonymous wrote:There’s a surface called callondoc that a lot of people who use that bound speak highly of. I have not used it because my plans specifically excludes weight loss drugs

I know for sure it’s covered. We picked this plan because they’re covered. Since I was on it and doing well.

[Anonymous]

Anonymous wrote:There’s a surface called callondoc that a lot of people who use that bound speak highly of. I have not used it because my plans specifically excludes weight loss drugs

I’ll look into it

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

Ok, this is a different situation than the office (I'm assuming the doctor doesn't submit these herself) refusing to submit the way the insurance is asking.

No advice, assuming that was clearly stated at the time you became her patient. If it wasn't, then you can point to that and say "no appeals" is a new policy that you should not be harmed by.

Even if it did say that when OP joined the practice, I don’t think it should apply when the need for an appeal exists because of provider error. It is generally expected that you fix a problem that you created even if you wouldn’t usually do the action that is the fix, assuming the action isn’t unsafe or unethical.

For example, I once ordered a dish in a restaurant, clearly specifying that the child it was for had a dairy allergy. It came out with cheese sprinkled on it. Even though the restaurant didn’t remake food, they made an exception and brought out a cheese free plate. Because they made the error.

This happened due to a doctor’s error, the doctor needs to fix it by submitting the appeal.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

None of the foregoing is relevant to the suggested action, which is for you to prepare yourself what you want submitted, along with gathering the necessary supporting data to submit with it, then meeting the doctor to get it signed/submitted.

The doctor isn't willing to sign and submit it, though. Would a bribe help? What would be a reasonable amount?

First of all, the principle reason the doctor “doesn’t do appeals” is that they don’t want to put in the time and effort for free. Signing and submitting a prepared package end runs this, and the physician gets paid for an office visit.

Second, unless OP has done this exact thing, nobody knows what the doctor will say.

Third, is it the actual physician who is refusing to help or an underling/functionary paid to get in the way? And what, if any, duty does the agreement between the physician and insurer say on this?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

None of the foregoing is relevant to the suggested action, which is for you to prepare yourself what you want submitted, along with gathering the necessary supporting data to submit with it, then meeting the doctor to get it signed/submitted.

The doctor isn't willing to sign and submit it, though. Would a bribe help? What would be a reasonable amount?

First of all, the principle reason the doctor “doesn’t do appeals” is that they don’t want to put in the time and effort for free. Signing and submitting a prepared package end runs this, and the physician gets paid for an office visit.

Second, unless OP has done this exact thing, nobody knows what the doctor will say.

Third, is it the actual physician who is refusing to help or an underling/functionary paid to get in the way? And what, if any, duty does the agreement between the physician and insurer say on this?

I am very hesitant to do an office visit given the constant reminders of “ we do not do appeals”. I might be better off with MIDI or something? I am not sure.

[Anonymous]

From nyt:
“There is an appeal process, which may differ by insurer. Contact a billing specialist with whatever information you have from your insurance company, though we may hear about it before you do and start the process on our own.

Sometimes, the problem is a relatively simple one, resulting from confusion over the byzantine process of submitting medical codes, or some similar snafu. But often, a doctor will have to do what’s known as a peer review with someone from the insurance company. We find this burdensome, since the “peer” on the line with us may not have the same level of expertise as we do. That prolongs the call, adds to our overall operating expenses and keeps us from spending more time with you, the patient.
We’ll give any appeal our best shot, but it may take time to schedule any peer review.”

https://www.nytimes.com/2025/09/14/business/doctors-prior-authorization.html?unlocked_article_code=1.rU8.9Fk4.LWSeuyyc8LPH&smid=url-share