As if that weren’t enough, compounding the compliance challenge are a couple recent trends that are negatively impacting patients, especially of Medicare age.
A New York Times report last month listed a host of repeated errors in Medicare Advantage plans, including improper claims denials and arbitrary and improper limits on coverage of prescription drugs. The data was based on dozens of federal audits of the plans, which are estimated to include about 16 million patients; another 23 million are in Medicare prescription drug plans. The study cited CMS findings including:
• In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.
• When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
• In 61 percent of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.
A second trend that may affect all patients, insured or not, is the runaway increase in the price of many generic drugs, a mainstay of treatment for many elderly and lower income patients. The increase has drawn the attention of Congress, which is investigating charges that the price of some generics has increased by more than 1,000 percent in the past year alone.
While ophthalmic products have not been singled out, several generics whose use is common in patients of Medicare age have. If your patients are choosing between a glaucoma drop or a post-cataract NSAID among the mix of other medications they’re prescribed, it’s not a stretch to imagine the eye drop losing out. Nor is it a stretch to see the price gouging trend extend to other generics. Why? As one observer said when asked why generic manufacturers would raise prices so dramatically: “Because they can. Who is to stop them? It’s unregulated.”