r/HealthInsurance • u/kynologia • Mar 14 '25
Claims/Providers Being charged $50 for prior authorization?
To start: I live in Texas, have Blue Cross Blue Shield HMO, and the relevant provider is in-network and my referral was already approved.
I have narcolepsy, and am about to start a specialty drug called Xywav for my treatment. It needs a prior authorization before I can start it, but the sleep neurology practice is charging me $50 to submit the prior auth. That seems insane to me, but I also really need the medication and don't know who I would speak to about this. I already called my insurance and they couldn't give me a solid answer, just that they had never heard of a prior authorization charge for someone in-network. This provider has been a shit show in general, but sadly there isn't an abundance of sleep neurologists.
Any suggestions for my next steps? Thank you.
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u/awwaygirl Mar 14 '25
That sounds like an office policy, not an insurance billing. Can you try another doctor?
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u/kynologia Mar 14 '25
Unfortunately they're the only sleep specialists in the area who treat narcolepsy. They've been terrible lately, and I was hoping there was something to be done about this. :(
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u/awwaygirl Mar 14 '25
OK - last ditch suggestion - talk to the consumer protection bureau for your state (run by the AG).
https://www.ohioattorneygeneral.gov/About-AG/Service-Divisions/Consumer-Protection
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u/One-Preference-3745 Mar 14 '25
Sorry, but should the office not be paid for their time in completing the prior authorization? Do you think so little of their time?
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Mar 14 '25
That should be included in the insurance payment/patient liability.
If they're in network, this is probably not even allowed in their contract with BCBS. @OP, id report it to BCBS and have their network manager contact the doctor. There is a very good chance they cannot bill you for this based on their in network agreement. When you or the insurance pays for the services, their PA efforts are reimbursed then.
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u/One-Preference-3745 Mar 14 '25
So, I work in healthcare as someone that completes these and also works with prior authorizations which are too complex for regular office staff to handle.
Believe me when I say the reimbursement for a prior authorization is not included in the office visit. It would be great if it was, but the reality is that it isn’t and pharmacy benefit managers go out of their way to make this process as difficult as possible.
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Mar 14 '25
Advocating for the patient is part of the job. The CPT code allocates an amount for office overhead. Preauth unambiguously is an overhead expense.
Whether the allocation from XYZ insurance is nearly enough is a different issue, but that’s the game we play and the rules we abide by when we sign with XYZ
If you value your provider, ask XYZ carefully about it so as to not invite a proctologist level audit of your claims.
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u/One-Preference-3745 Mar 14 '25
Yes I agree with advocating for the patient. But at the end of the day healthcare workers need to be paid for the services they provide. And in my opinion that includes the staff working under the providers as well.
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u/SuspiciousCranberry6 Mar 15 '25
I investigate medical insurance fraud. I'd recommend practices run separately charging to do a prior authorization past their attorneys because part of the reimbursement for E&M codes includes administrative costs. It's likely better to negotiate a higher administrative reimbursement portion of E&M codes with your commercial insurance contracts to avoid poor audit outcomes.
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u/One-Preference-3745 Mar 15 '25
So, a prior authorization would be done separately from the initial E/M visit (ie not the same day). I would think that would be fraud if you charged for that service during the E/M visit when it wasn’t provided?
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u/Kitchen_Philosophy29 Mar 17 '25
It's supposed to be covered in costs
If they feel they aren't being paid enough they should take it up with insurance
It doesn't make sense to charge a patient insurance and additional fees
Insurance should be compensating then
There is a reason why it is in the contract between the physician and the insurance company
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u/One-Preference-3745 Mar 17 '25
Well what happens then are contracts being dropped between provider offices and insurers due the insurers not reimbursing enough. I don’t think that’s a fair solution either.
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u/Kitchen_Philosophy29 Mar 17 '25
Average American makes 65k a year
Single person insurance average is over 8k. And 25k for family
Insane to say that the sick person that needs meds should foot the bill
Besides it being unethical in the links I sent you
It looks like most insurance companies have contractual agreements not to charge patients for this service
They ask that patients reach out to them if their Dr is doing this
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u/snotick Mar 14 '25
Ok. I guess we should also be prepared to tip our doctors, nurses and staff.
Is 18% still the standard?
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u/One-Preference-3745 Mar 14 '25
Do you believe that healthcare workers should be reimbursed for the services that they provide? Or that they should work for free? That is the question at hand.
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u/snotick Mar 14 '25
Do you believe that healthcare workers should charge outside of insurance, if there is insurance and it's in network?
Seems like this is the start of a dangerous precedent. What's to prevent them from just creating charges to bypass insurance companies?
I do believe that healthcare workers should be reimbursed for services. The same way I think that waiter and waitresses should be paid a fair wage. It's up to the business to make sure their business model covers those expenses.
I'd compare this type of activity to nickel and diming you see in Vegas. You rent a hotel a $99 a night, but once you check in, they add $50 in resort fees. If you can't wave those fees, then it's just the total cost. Don't bait and switch.
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u/One-Preference-3745 Mar 14 '25
Yes, as long as the services and charges are explained beforehand and consent is obtained for those services. Obviously I’m not in favor of fraudulent billing.
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u/snotick Mar 14 '25
So if the total cost is $5k and the person has a $35 copay, what does the $50 for preauth go to? The co-pay? Out of pocket that's not covered by insurance?
And more importantly, why isn't that $50 just included in the total cost? Make it $5050. The obvious answer is because they know insurance will only pay for $2500. So, they are finding a way to make more than insurance will pay.
Why not $500? Why not $1000? That's the point.
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u/One-Preference-3745 Mar 14 '25
If we’re talking about solely billing through insurance, then those reimbursement rates are based on the specific service code billed.
Let me give you a personal example as it applies to what I do. Patient meets with doctor for a visit, and his insurance is billed specifically for the services provided during that visit. BUT, the patient is then prescribed a medication for management of that condition that requires extra services in obtaining that medication outside of the original visit.
My reimbursement rate for services rendered would be about $60 based on CPT 99490. These services would include navigating insurance restrictions or looking at grant/assistance programs to make sure that patient received that medication.
Do you believe that I shouldn’t be reimbursed for the services I described above?
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u/One-Preference-3745 Mar 15 '25
Let me add this too. Each time I provide this service, I usually save one patient about $1500-2000 in prescription costs over the course of the year.
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u/SuspiciousCranberry6 Mar 15 '25
Obviously I’m not in favor of fraudulent billing.
I'm not sure if you know enough about insurance contracts to know that you are likely indeed advocating for fraudulent practices. Most commercial insurance contracts have a number of restrictions separately charging for prior authorizations could violate and it absolutely violates Medicare policy.
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u/Kitchen_Philosophy29 Mar 17 '25
Move the goal post more
They get paid. They charge the patient and Insurance
If you don't move the goal post it is obvious that the workers should be charging insurance not the patient
The fact that you can go in for one thing and then get 5 extra bills that you never agreed to would be fraud in any other setting
The fact that I can't ask to even find out how much it will cost is also insane
I just went in for a "routine exam" and got hit with a 2 thousand dollar expense and was charged 7 different times
I pay a fortune for high end insurance
It is insane to think that the average American is paying a significant portion of their pay for medical
Why should I be paying the equivalent of a mortgage for services that I hardly utilize
It is absurd to be asking the patient for more money
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u/One-Preference-3745 Mar 17 '25
So is it the healthcare offices fault or the insurers that your costs are so high?
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u/Kitchen_Philosophy29 Mar 17 '25
Costs are supposed to be with your fee
If your paying out of pocket for pre auth then it doesn't go to insurance
I don't know how old the info is. What I have been reading is that most insurance companies have contracts with Dr and that they aren't allowed to charge u contractually (unless out of network)
I've been digging to get confirmation
Why should I pay for insurance if I get charged out of pocket as well
Also. This, don't they deserve to be paid? The goal of a general practitioner is to see 7-9 patients an hour. Each gets billed 300-400
It is hard to feel bad for the Dr office when they are making 8 times or more a year than I do
Yes it sucks for them. But it seems like hospitals and Insurance are out to screw the sick people, seems like Dr want to join in
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u/kynologia Mar 14 '25
I never said that, at all. Please don't put words in my mouth.
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u/One-Preference-3745 Mar 14 '25
Sorry, my comment wasn’t directed at you. It was directed at awwaygirl.
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Mar 14 '25
Yes, I’ve encountered doctors who charge an admin fee if they have to submit prior authorization because they “don’t get reimbursed for spending hours on the phone with my insurance”.
Also in Texas. 😒
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u/kynologia Mar 14 '25
Yeah, that makes sense... It is also a ridiculous, and I mean RIDICULOUS, specialty medication. But $50 on top of everything else I'm already charged just feels so unfair.
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Mar 14 '25
Because this medication is a specialty med from a narcolepsy doc, there will likely be sleep studies required etc, the insurance co will likely have crazy bureaucratic hoops to jump through and therefore the process takes a long time and is mind numbing for the office. I get why they’re charging the fee.
Once approved, ask the office how long the process took for them to get your med approved. File a grievance with your carrier. It won’t change what happened, but those stats have to be reported to the states department of insurance.
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u/kynologia Mar 14 '25
I was diagnosed back in 2016 so I don't need another sleep study, and I've been a patient at this practiced since 2021 as well. The medication is crazy complicated so I do sort of understand the inconvenience on their part, but me having to pay an extra $50 for the prior auth is just not cool. I'll be sure to document it all somewhere, at least.
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u/Big_Echidna8511 Mar 14 '25
You may need a recent sleep study within the last 180 days….. for PA they want recent records and if you haven’t had one done recently then it could be denied for lack of documentation…. I work in pharmacy insurance dealing with PA…..
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u/jeswesky Mar 14 '25
It definitely sucks. I work in healthcare and pretty much everything needs a prior authorization for what exactly we are doing so we have people whose job it is to get those authorizations. There are days they will be on the phone for 4+ hours just trying to get authorization on a single patient. What’s really fun is when we bill the insurance later and they turn around and deny it and we have to fight to get paid.
We don’t charge patients for prior auths, but based on my experience with them I can understand why some places do. It just sucks that’s being pushed off on the patient and not on the insurance.
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Mar 14 '25 edited Mar 14 '25
Insurance companies use PAs to try to control the extremely high cost of health care. I can understand your frustration on a $50 drug, but thats very unlikely. Its the $10k drugs or $10k procedures. Member's employers want these steps in place as usually they're the end payer. PAs are a result of how expensive health care has become. Some doctors don't need that 2nd house or 3rd boat at the expense of their patients.
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u/New_Olive1203 Mar 14 '25
The $50 is the Admin fee for the provider's office to obtain a Prior Authorization for OP.
I'm on a sister medication and when I first began taking the prescription years ago, the retail price for a year supply was similar to starter family homes at the time. 🥺
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Mar 14 '25
Thats why the PA is there. Someone has to pay $250k... they want to make sure it's necessary. You have to sell a lot of policies to pay for a $250k/yr drug. Id be willing to bet a starter family home that the proivder already agreed to not bill the members for requesting a PA. Its very likely in their contract and they'll bring this up next time rates are open for negotiations.
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u/yuricat16 Mar 15 '25
Once upon a time, PAs were required only for the most expensive treatments and therapies. But now they’re required in the most ridiculous of circumstances, like generic drugs off-patent for over a decade that cost me $20 cash. (Would have been even less if used GoodRx or Cost Plus Drugs.) That’s just absurd and a waste of time.
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Mar 15 '25
Then don't request the PA and send the member to GoodRx... insurance is paying $75+ per auth for a clinician to review the auth. I highly doubt they're putting PAs on $20 drugs unless there is a safety issue. (Most) Insurance has no incentive to require a PA in that situation unless it's some ridiculous PBM that is going after every penny and that's what they sell to the employers.
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u/yuricat16 Mar 15 '25
I am the patient and when I got to the pharmacy and learned a PA was needed, I just paid cash (even though I’d already met my OOP max and insurance would have covered 100%) because I thought a PA was absurd. Caremark is the PBM.
I’ve run into this situation before, PA required for an inexpensive generic without anything comparable on the formulary. It makes no sense bc it’s more costly to evaluate the PA, as you point out, unless the objective is to discourage people from filling using insurance at all. Which is a possibility, I guess.
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u/Kitchen_Philosophy29 Mar 17 '25
The objective is to slow down patients from getting meds
If you can delay every script being filled by 2+ days when your looking at billions and billions of dollars. It saves them a lot of money
It costs the Dr and patients. But if someone tells u it costs the insurance company money, they are naive or lying.
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u/Kitchen_Philosophy29 Mar 17 '25
"Generally, in-network doctors are responsible for submitting prior authorization requests for covered services and should not charge you for this service, as it's part of their contractual obligations with Blue Cross Blue Shield"
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Mar 14 '25
I spent 480 (copay 80) on a 45 min rack that took 3 mins (and x mins offline to review X-ray etc)
Like every other aspect of USA, there is something very corrupt
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u/Important-Region143 Mar 14 '25
I also don't get reimbursed specifically for each fax I send or phone call I make. I factor that in to my overall rates like any competent office professional should.
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u/Hopeful-Chipmunk6530 Mar 14 '25
I work in family medicine. There has been a dramatic increase in insurance companies requiring prior authorizations for medications. We get them for medications that are very cheap and been around a long time. We are looking to hire another person in our office because of the increased time spent on doing PAs. The insurance companies do not pay for our time to do these. This costs our office money, especially as we are going to have to hire another person. While I understand your frustration at the fee, I do think we will see more physician offices adopting a policy of charging for PAs. Since the insurance companies won’t pay for it, the cost will get passed on to patients.
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u/milespoints Mar 14 '25
Not only this, but there are some insurance companies - won’t say which one, but it sort of sounds like UHSEE - have been making it a point of randomly denying PAs across the board for no real reason except to make life hard and have the provider have to call them, wait on hold, etc.
None of this time is compensated for the physician or their staff.
It’s pretty insane to charge a patient for PA time.
But OTOH, it’s pretty insane what insurers are doing to pnysicians
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u/kynologia Mar 14 '25
Thank you for the explanation! It's terrible that the physicians are getting screwed over too, I hate how it all trickles down. I just really don't have the money to easily pay that (since I do have narcolepsy, I can only work limited hours) and I'm really disappointed with this office over all.
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u/Bruton___Gaster Mar 14 '25 edited Mar 15 '25
Agreed with the above. Some offices have some paper/admin fees (ie if you need a form filled out without a visit associated with it, etc). This feels akin to that, though I’ll admit a bit extra. There’s some health systems implementing fees for messages (due to the overwhelming number of those as well). A lot of stress points in a system which seems to land on patients and frontline clinical staff to bear the brunt of.
I’ve gone as far as asking patients to ask their insurance what medication would be covered for weight loss and they were told they couldn’t tell the patient, all the while they had an exclusion for any weight loss medication which we found out after prescribing and completing a prior auth for 2 medications.
I’m comfortable blaming insurance for a lot of the nonsense with everyone around just coping. They’re happy to require a PA to “reduce waste” but put up opaque barriers to determine what’s covered, have multiple steps for PAs with 48 hour turnaround before automatically declining, etc. if they wanted, they could actually just let us prescribe what we thought was necessary…
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u/Kitchen_Philosophy29 Mar 17 '25
They really aren't
GP are getting paid more every year. They make over 4-5 times the average American (who also on average pays 9% pretax of their salary for insurance, while also paying for copays)
GP in the USA are paid more than any other in the world (including adjusting for inflation)
Most medical ethics paper say it is unethical
Most major insurances say that you should contact them because most Dr are contractually not allowed to charge for pre auth.
All of this is of course silly. It is called the cost of business. Just like how almost every working person puts in more than 40 hours a week when they are salaried and don't get more money.
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u/Kitchen_Philosophy29 Mar 17 '25
"Generally, in-network doctors are responsible for submitting prior authorization requests for covered services and should not charge you for this service, as it's part of their contractual obligations with Blue Cross Blue Shield"
I know BCBS advocates patients to contact them if the Dr is charging for prior authorization
I'm sorry it is costing you more. But last time I checked.... General practitioners in the USA make more than the rest of the worlds, they make 4-5 times more than the average American (who also pays an average of 9 percent of pretax income for insurance)
I would encourage you to also explore ethics texts that address this specifically. Most of which say... It is unethical
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Mar 14 '25
Charging for fmla and disability forms is standard now. Those are courtesy services that take a lot of time to do and divert my staff from other stuff like your authorization. As for the preauth, your provider is treading dangerously there. Whether he likes it or not, he’s been paid for that work when he saw you and wrote the script. That’s part of his job once he charges you for the visit. That’s directly related to care. I would write them and gently point that out and copy your plan administrator. The provider is going to find out quickly this ain’t cool
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Mar 14 '25
Yeah if your insurance company doesn't prohibit it, there's probably not much you can do.
It's annoying, but it's real work for providers and their staff to do these prior authorizations. The insurance company certainly isn't paying them anything for it, and they don't want to do it for free. So they don't have many options except to bill the patient.
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u/crazybandicoot1973 Mar 14 '25
So basically, cough up $50 or die. I had a doctor office when I first came down with diabetes made me have visits 3 times a week. I told them I make $9 an hour and couldn't afford that. They said dont worry about it they would work with me. We agreed to $50 every two weeks. My bill hit $3000, and they wouldn't give me my diabetes meds or see the doctor until I paid the $3000 in full. Well, as you can imagine, I got deathly sick. It's all about greed and doctors don't care if they kill someone as long as they can take everything you have.
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u/Kitchen_Philosophy29 Mar 17 '25
I encourage you to file an official complaint with the state medical board
You probably don't have proof of a written agreement. So it would just be a flag on them. But if they already have them, the state should Intervene
Plus, charging u more than the agreed price is fraud
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u/Kitchen_Philosophy29 Mar 17 '25
If insurance doesn't. At the very least point out the medical ethics papers saying it is unethical. That most insurance companies don't let them
Cc it to your insurance admin
Also look for a handful of reviews sites and post about what happened
If it becomes to common Dr will start to see lawsuits. Having a patient, knowing they need medication, charging for them to be able to get the medication when it isn't the pharmacy ... It is standard malpractice
"Rather, a healthcare professional must meet a threshold “standard of care” in treating and prescribing medication to their patients. A medical review board will find a doctor to have met an appropriate standard if the doctor acted as a reasonably prudent, similarly-qualified healthcare provider would have under the same or similar circumstances."
Unfortunately, if you file an official complaint with the state medical board; while they will probably be reprimanded, they will drop the patient
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Mar 17 '25
What medical ethics papers say it’s unethical? Do you expect doctors to work for free?
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u/Kitchen_Philosophy29 Mar 17 '25
Your moving the goal post
I posted some papers
Look up the law for denying patients medication
Dr get paid. You just want patients to pay their costs of business
Dr get paid on average 4-5 times more than the average American. (Who already pay on average 9 percent of their income pretax on insurance)
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u/External-Prize-7492 Mar 14 '25
Prior auths are a Pain in the behind. They can take peer to peer reviews, a lot of paperwork and time. They are likely charging because they know it’s not going to be easy.
It’s an office policy—not an insurance issue.
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u/Kitchen_Philosophy29 Mar 17 '25
Most insurance companies have a contract with Dr not allowing them to charge for it
I know BCBS says you should call and inform them if they are
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u/New_Olive1203 Mar 14 '25
Were you aware of the Prior Authorization fee before the doctor wrote the prescription? This is the first time I've heard of a fee for a prior authorization, but I'm not surprised at all. Unfortunately, I have needed many PAs thanks to multiple chronic conditions.
I saw your comment about not loving the sleep specialist's support staff. If you haven't been on the Xwayv website yet, go take a look around. They have a database of doctors that are already enrolled in the REMS prescribing program; you would have to cross check individual profiles against your insurance companies website for coverage.
Big hugs to you from a fellow PWN! -off to nap 🫂
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u/Forward-Wear7913 Mar 15 '25
I was recently charged $400 to have my surgeon write a paragraph supporting approval for surgery.
There needs to be some major changes as the doctors’s offices are not wanting to cover the administrative costs.
There should be a way for insurance to have to pay them for the services as they are requiring them in order to provide authorization.
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u/Kitchen_Philosophy29 Mar 17 '25
The biggest problem is that this is one of the many, many, major issues with the US medical system
Dr hospitals and insurance are all playing games and the patients are the ones who get screwed the hardest
The government is supposed to protect civilization. Hell, for the price that the average American pays for insurance (over 8k a year)... We could have universal healthcare
We don't even need universal healthcare. We could just dissolve standard insurance companies and go to a self pay system and it would also be far better
We are in a worst case limbo of not universal health care and not free market
It is the same stupid issue as the costs of college. (At the very least the government should put a cap on the maximum inflation of tuition fees yearly). There is no reason some universities should be able to take a double digit portion of a states tax dollars and still have astronomical tuition fees (university of Texas)
Itd be great if politicians could be civil servants again
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u/Bob_EzMedAppeal Mar 16 '25
You should absolutely file a grievance with your insurance company—this provider should not be charging you to submit a prior authorization (PA), and this delay in care needs to be addressed immediately.
📌 Here’s what you can do next:
✔️ File a grievance with Blue Cross Blue Shield (BCBS) stating that your in-network provider is improperly charging you for a required prior authorization and delaying access to medically necessary treatment. BCBS needs to step in and address this with the provider.
✔️ Demand that BCBS find you another in-network provider who will process your prior authorization without unnecessary fees and delays. It is their responsibility to ensure you have reasonable access to care.
✔️ Push back on the provider’s charge—you can contact their billing department and ask where this policy is written. Many providers will back off when questioned.
Your provider should not be creating barriers to your care. Demand action from your insurance now—this is urgent, and BCBS needs to fix this immediately. 🚀
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u/kynologia Mar 16 '25
Thank you for such a thorough answer!! My only fear is retaliation from my sleep neuro... this is the only office in the entire city that is equipped to handle narcolepsy care.
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u/Kitchen_Philosophy29 Mar 17 '25
If they are charging. Most will at least put it into the contract policy
But at some point it also wouldn't hurt to reach out to the government. Specifically the state medical board
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u/One-Preference-3745 Mar 14 '25
Well deserved. I don’t think you realize how much effort goes into to completing prior authorizations. Can easily became an hours worth of staff time.
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u/kynologia Mar 14 '25
I just haven't heard of in-network providers billing for PAs before. I definitely understand why they deserve the compensation, but not why the insurance itself doesn't pay for that.
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u/One-Preference-3745 Mar 14 '25
It’s not common practice, but honestly that is probably where we are going. The margins that health care offices work on are extremely thin and so in order to be able to maintain their ancillary/administrative staff, this will probably become more commonplace.
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u/Kitchen_Philosophy29 Mar 17 '25
No they aren't
Dr offices are some of the most successful small businesses
They make several times over what the average American makes
They make more than any other GP in the world accounting for inflation
I'm not sure why your trying to ask the average American making less than 1/4 of the income to feel bad that your not getting paid enough
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u/One-Preference-3745 Mar 17 '25
Prove it. Where’s your data coming from? Why are rural hospitals closing across the nation?
Show me your data.
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u/Kitchen_Philosophy29 Mar 17 '25
It's your practice
It's on YOUR best interest to spend some more time reading up
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u/One-Preference-3745 Mar 17 '25
You’re the one making the claim. Prove it.
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u/Kitchen_Philosophy29 Mar 17 '25
Haha
It's not my medical practice on the line
I could care less if you lose your license
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u/Kitchen_Philosophy29 Mar 17 '25
Every other business in the USA accounts for expenses
Remember your ethics
Also hope your patients don't start informing BCBS
You can't legally deny medicine on unethical grounds.
" A healthcare professional must meet a threshold “standard of care” in treating and prescribing medication to their patients. A medical review board will find a doctor to have met an appropriate standard if the doctor acted as a reasonably prudent, similarly-qualified healthcare provider would have under the same or similar circumstances."
"With respect to prescribing medicine, healthcare providers have an ethical duty to evaluate the patient, specify the therapeutic objective, be well-informed about current medications on the market, and prescribe the most appropriate medication in their clinical judgment. The physician should also discuss the treatment plan with the patient, provide essential details and instructions, and carefully monitor the treatment."
A lot the very least it is more than worth it not to have to pay legal fees for the inevitable official medical complaints
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u/One-Preference-3745 Mar 17 '25
You keep quoting statements but fail to provide a reference. What are you hiding?
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u/Kitchen_Philosophy29 Mar 17 '25
I posted them. Specifically to you as well
What's the name of your practice? I'll lodge a formal complaint with the state medical board if your doing this
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u/Apart-Routine-2032 Mar 14 '25
Not specifically related to your question about PAs- but jazzcares has a copay card that you should use alongside your insurance! As well as a one time use assistance that allows for 1 month free while you are waiting on the pa approval. I’ve seen doctors jump through hoops to get a medication “approved” only for the copay to come back at $400 still 🙄 I hope you don’t pay the $50 just to hear insurance denied the authorization or they approved it but it’s still unaffordable!
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u/kynologia Mar 14 '25
Thank you for the tip on Jazz! I'm really desperate at this point re: narcolepsy, which is the only reason I'm even going through all this pain :(
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u/New_Olive1203 Mar 14 '25
Were you aware of the Prior Authorization fee before the doctor wrote the prescription? This is the first time I've heard of a fee for a prior authorization, but I'm not surprised at all. Unfortunately, I have needed many PAs thanks to multiple chronic conditions.
I saw your comment about not loving the sleep specialist's support staff. If you haven't been on the Xwayv website yet, go take a look around. They have a database of doctors that are already enrolled in the REMS prescribing program; you would have to cross check individual profiles against your insurance companies website for coverage.
Big hugs to you from a fellow PWN! -off to nap 🫂
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u/kynologia Mar 14 '25
Fellow sleepyhead!
I wasn't told anything about the fee, the way I found out was after completing all of the REMS forms... My sleep neuro office emailed me about finishing the prescription forms on their end, and I was so excited! Until it said that in order to submit it, I had to pay the $50 fee.
Thank you for letting me know about the database!
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u/New_Olive1203 Mar 14 '25
You're so welcome!
They sound a bit stinky to me. 🦨 I hope the PA goes through relatively easily and you start seeing some relief.
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u/Kitchen_Philosophy29 Mar 17 '25
They can't legally charge u if it isn't in the policy.
I suggest calling administration and asking where It is in the policy.
Hopefully they get the message. You'll get dropped off you file an official medical complaint with the state.
You can also inform your insurance and they can intervene
It is malpractice
If it is in the policy it is more gray area. Dr keep trying to get more money but they are risking a lot in the process
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u/AP_Cicada Mar 14 '25
Is it perhaps a consultation bill for preparing the sleep study? All I can think is that it's a doctor visit charge of some sort rather than a fee for the preauth
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u/kynologia Mar 14 '25
This was on top of the $45 copay I owe and already paid :( I also don't need another sleep study since I already had multiple to lead to my diagnosis. I filled out all the other relevant forms (Xywav has a REMS program) and wasn't told about the PA fee.
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u/Prior_Particular9417 Mar 14 '25
The office is under no obligation to submit a prior authorization and there’s lots of work that goes into this. It sucks but your other choice is to start over at a different provider.
1
u/Kitchen_Philosophy29 Mar 17 '25
Yes they are. Are you not aware of medical malpractice?
I encourage you to look up the law regarding denial of medication
This isn't a medical or ethically deniable action
This even ignores the extremely common contracts Dr sign with insurance saying they can't do this
1
u/Moose5846 Mar 14 '25
Just how do I claim the money on my taxes? Is it part of the bill or part of a tip?
1
u/Kitchen_Philosophy29 Mar 17 '25
LOL
But....
you call the state medical board and file a formal complaint for malpractice
1
u/Calm-Vegetable-2162 Mar 14 '25
If they are an in-network provider, tell them to bill the insurance company for the fee.
The insurance company will deny the charge and send you an EOB, indicating that your portion is $0.00. Take that EOB to your provider and pay the $0.00 immediately. Rinse. Repeat.
Chances are, the insurance company will discipline them for charging the fee.
1
1
u/Emotional_Wheel_7140 Mar 14 '25
Why would it be $0?
1
u/Calm-Vegetable-2162 Mar 17 '25
Because it is not an approved procedure. Your insurance sets the amount that you are responsible for, not the provider. Since its a unapproved procedure (based upon the insurance contract that the provider and insurance company signed), both the insurance company and your responsibility is $0.00.
1
u/Kitchen_Philosophy29 Mar 17 '25
PA isn't a procedure. But most insurance companies say to do exactly what you recommend
1
u/Calm-Vegetable-2162 Mar 18 '25
I've been down this road at least once.
Most people would just pay the bill and move on, however what the provider is doing (billing for a PA) is against the written contract the provider has with the insurance company. The in-network provider is not allowed to bill the patient anything other than the amount of the "patient responsibility" listed on the EOB. Billing anything more is insurance fraud.
1
u/Actual-Government96 Mar 14 '25
You could ask your insurer if it's allowed per the providers contract. It seems odd that an HMO PCP would do this considering that their reimbursements are at least partially based on capitation (paid per patient, not necessarily per service).
2
u/kynologia Mar 14 '25
This isn't my PCP, this is my sleep neurologist, so a specialist. I don't know if that changes the situation.
2
u/Kitchen_Philosophy29 Mar 17 '25
Specialist shouldn't matter. (It might vary by state)
They can charge whatever they want if your out of network
I've had my 2 sleep Dr in my area do this to me
The first I filed a formal complaint with the state board and they were reprimanded
2
u/Actual-Government96 Mar 14 '25
Oh, sheesh, my bad, I need more coffee. Yeah, that might make a difference from the insurance side. It also makes the Dr sound like more of a jackass IMHO.
1
u/Sea_Egg1137 Mar 14 '25
Ask them to type on their letterhead and you can submit to BCBS. Maybe they’ll do that for free.
2
u/kynologia Mar 14 '25
Huh, that's an interesting idea. I'll ask, because honestly my sleep neurologist herself is great, it's just the practice/office that really like to make my life difficult.
0
u/DivideLow7258 Mar 14 '25
How much more proof do Americans need that MDs and other medical providers are just as involved as the insurance industry in creating the mess that our healthcare system has become? Managed Care, and all its rules, regulations, and absurd bureaucracy has been around since the 1970s. Providers need to get payment approvals from Insurance plans. The end. It’s how it works. Sorry you don’t agree. Maybe move to Sweden and open a medical practice there? This is bullshit.
1
u/kynologia Mar 14 '25
...? Don't know why this is your response but okay, thank you.
0
u/DivideLow7258 Mar 14 '25
Lol. I’m “speaking” to your MD, OP. Not to you. What unethical arrogance to charge you for an administrative task that’s their responsibility.
8
u/Hopeful-Chipmunk6530 Mar 14 '25
No one is obligated to work without compensation.
3
u/TheMonkeyPooped Mar 14 '25
Unless they have signed a contract with insurance to not charge this type of fee.
2
u/pellakins33 Mar 15 '25
The facility employs all sorts of staff that patients aren’t charged a fee for. I don’t pay a fee because the scheduler has to book a higher than normal amount of appointments for me. It’s not unreasonable to expect that this would be baked into the price just like all of the other clerical work that gets done
1
u/Kitchen_Philosophy29 Mar 17 '25
In sorry what business doesn't have to account for business expenses
Who gets to walk out of their office when they are salaried because they met 40 hours?
They are compensated
1
u/kynologia Mar 14 '25
Of course! I do wish they were paid by the insurance company so the burden didn't fall on me though, and I wish there was a fair way to contest it. $50 is something I do not have.
2
u/Kitchen_Philosophy29 Mar 17 '25
The Dr and insurance are in a contract
Most contracts say that Dr aren't allowed to charge prior authorization
It is also medical malpractice to deny medication for unethical and nonmedical reasons
1
1
u/Kitchen_Philosophy29 Mar 17 '25
It is bs
Unfortunately the biggest issue is the lack of government enforcement. The government has an obligation to protect civilization
Dr are less responsible than hospitals and insurance
But going free market or universal healthcare would cost less than the 9 percent pretax income of the average American paying for insurance (of course ignoring all the other fees we get to pay)
Pharmaceuticals are also guilty
But Americans are paying WELL. Over 60 percent on average for all drugs. Hospital pharmacies charge over 50 percent more when your in the hospital for medication
Then we can also blame universities, because for some stupid reason there is an insane barrier to get into medical school. Even though we have to import over 60 percent of our doctors who have lower qualifications
But politicians are too busy fighting about 3 people taking hormones playing in highschool sports. It is three people! Let's focus on some real issues here
The US government has really been following behind the rest of the modern world in governing.
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Mar 15 '25
[deleted]
2
u/kynologia Mar 15 '25
I don't???? Insurance should absolutely pay them, but it's also not fair that it falls on the patient to pay on top of everything else I'm already paying for, like my insurance and copay. I was not told about the fee at all, they have already messed up my billing multiple times in the past, and an additional $50 isn't cool to just spring on someone. Calm down, I really don't appreciate your attitude man.
1
u/Kitchen_Philosophy29 Mar 17 '25
Sry. Do you not pay your Dr when you go?
Do teachers get paid to grade papers after school?
What business doesn't have business expenses. There is a reason it is tax deductible
•
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