I had the opportunity to take care of a patient with unexplainable chest wall pain of three weeks duration. I had no idea why they were having pain. They had a complete CT scan of their chest that essentially ruled out a pulmonary embolism with high probability. They had a full series cervical through lumbar MRI. They had an entirely normal laboratory work up with no evidence of inflammation. They had no red flag symptoms that would suggest the need for further workup
Like so many patients I see, the diagnosis remains a mystery and I'm forced to explain to the patient that things that remain unexplained will either
- Go away on their own or
- Eventually declare themselves one way or another
Day in and day out I explain to patients that when the work up has been done and no red flag symptoms are present, time is our best diagnostic and therapeutic treatment. What did I do with this patient? I sent them home with a cocktail of pain medications and the only thing that seemed to help before discharge a Lidoderm pain patch.
Lidoderm is a topical transdermal delivery system for lidocaine. It's expensive and some insurance companies require pain patch Lidoderm preauthorization. Heres' how that played out. I received a text at almost 5 pm on a Wednesday afternoon to call a 1-800 number to preauthorize a Lidoderm pain patch I had ordered upon discharge two days previously. Apparently, the pharmacy couldn't fill the script without preauthorization.
I called the number while driving to Walmart to pick up diapers. Here's how that conversation went.
Pain Patch Lidoderm Preauthorization rep: Hello, thank you for calling. May I have your name?
Happy: Dr Happy.
Pain Patch Lidoderm Preauthorization rep: Thank you. Can I have your national provider number?
Happy: I don't know what you're talking about
Pain Patch Lidoderm Preauthorization rep: Your NPI number.
Happy: I don't know what you're talking about.
Pain Patch Lidoderm Preauthorization rep: Can I get your DEA number?
Happy: Yes. XXXXXXXX
Pain Patch Lidoderm Preauthorization rep: I'm sorry, I'm not finding you
Happy: This is Dr Happy. I'm the only one.
Pain Patch Lidoderm Preauthorization Rep: Can I have your DEA number again?
Happy: Yes. XXXXXXX
Pain Patch Lidoderm Preauthorization Rep: OK I found you. Can I have the patient's name?
Happy: Let me check my text. OK. It's Jane Doe.
Pain Patch Lidoderm Preauthorization Rep: Do you have her date of birth?
Happy: No. I'm driving to Walmart. All I have is a name. Jane Doe.
Pain Patch Lidoderm Preauthorization Rep: OK, I think we can figure this out. There she is. What can I do for you?
Happy: I was asked to call to preauthorize a Lidoderm pain patch.
Pain Patch Lidoderm Preauthorization Rep: OK. I just need to ask you a few questions. Does the patient have neuropathic pain?
Happy: I don't know. She has pain that responded to a Lidoderm patch in the ER. I don't know the cause of her pain.
Pain Patch Lidoderm Preauthorization Rep: Is that a yes or a no?
Happy: I don't know. She has pain that responded to a Lidoderm patch in the ER. I don't know the cause of her pain. It could be neuropathic or it could be muscular-skeletal in nature. I just don't know.
Pain Patch Lidoderm Preauthorization Rep: I'm sorry. I cannot approve your patch. I will have to send it on to a pharmacist for additional review. It may take several business days to complete.
Happy: No. We aren't playing this game. I'm sitting in a Walmart parking lot waiting to get diapers and I'm not working for another week, so we are going to settle this now.
Pain Patch Lidoderm Preauthorization Rep: OK, I'll place you on hold and speak with our pharmacist
On hold....five minutes laterPain Patch Lidoderm Preauthorization Rep: I spoke with our pharmacist. We can not approve your patient's Lidoderm pain patch with the current diagnosis of pain.
Happy: That's OK. Just let me know what anesthetic pain patch you can preauthorize so my patient can get relief from her pain.
Pain Patch Lidoderm Preauthorization Rep: clicking away on a keyboard. It looks like we can approve a Flector patch for her pain.
Happy: Flector is a nonsteroidal. My patient has already failed a trial of nonsteroidals. Would you please tell me what anesthetic patch you can approve so my patient can continue to get relief from her pain.
Pain Patch Lidoderm Preauthorization Rep: I'm sorry. We cannot approve an anesthetic patch at this time based on your diagnosis of pain. Does your patient have neuropathic pain.
Happy: OK. How about yes. Yes they do. They have neuropathic pain.
Pain Patch Lidoderm Preauthorization Rep: OK doctor. We have now approved your patient's Lidoderm patch. Her copay will be $50 for a daily one month supply. Is there anything else I can help you with?
Happy: No. Thank you.
And this is the preauthorization madness we deal with every day. It's a good thing I have people that shield me from this madness. It took me 20 minutes on my day off driving to Walmart to pick up diapers on a late afternoon to get the therapy approved for my patient. I can't even imagine what it's like doing this 50x a day in an office setting.
But I learned something important that day. If I ever have a patient with pain and they need a Lidoderm patch prescribed, they may have neuropathic pain until proven otherwise, even though I can't exclude fibromyalgia pain, musculo-skeletal pain, or psychosomatic pain. And this is why concierge medicine is going to expand by leaps and bounds. It's not just Medicaid preauthorization for vitamins madness that is degrading the doctor-patient relationship. It's all third party insurance rules and radiology management madness. As physicians get squeezed with uncompensated busy work, either the patient is going to pay an administrative fee for the right to be their insurance company's liaison or the insurance company will pay. And guess who's going to lose that battle. Doctors are charging for emails, phone calls and filling out disability and FMLA paperwork. Good for them. It's time preauthorization was a compensated administrative fee.