Getting the Most Out of Your Remote Healthcare Visits

This content originally appeared on Integrated Diabetes Services. Republished with permission.

By Gary Scheiner MS, CDCES

A long, long time ago, before the days of coronavirus, there was a little diabetes care practice called Integrated Diabetes Services (we’ll just call it IDS for short). IDS taught people with diabetes all the wonderful things they can do to manage their diabetes. Word got out, and people who lived far from IDS’s local hamlet (better known as Philadelphia) wanted to work with IDS. Even people IN the hamlet wanted to work with IDS but were often too busy to make the trip to the office. So IDS had an idea: “Let’s offer our services via phone and the internet so that everybody who wants to work with us can work with us!” The idea took off, and IDS grew and grew.

And virtual diabetes care was born.

Today, in response to the COVID-19 pandemic, virtual healthcare has become a virtual norm. Often referred to as “telehealth” or “telemedicine,” people with diabetes are connecting with their healthcare providers for everything from medical appointments to self-management education to coaching sessions. Some consults are conducted via phone calls, while others utilize web-based video programs (like Zoom) or simple email or text messages. Regardless of the form, virtual care can be highly effective. But it can also have its limitations. Whether you’ve been receiving virtual healthcare for months or have yet to give it a try, it pays to learn how to use it effectively. Because virtual care will certainly outlive the pandemic.

What Can… and Can’t… Be Accomplished Virtually

Most diabetes care services, including medical treatment and self-management education, can be provided effectively on a remote basis. We have managed to teach our clients everything from advanced carb counting techniques to strength training routines to self-analysis of glucose monitoring data, all while helping them fine-tune their insulin program, on a 100% virtual basis.

Some clinics and private healthcare providers have gone 100% virtual since the pandemic began, while others are using a “hybrid” approach – periodic in-person appointments with virtual care in-between. Depending on the reason you’re seeking care, a hybrid approach makes a lot of sense. While virtual visits are generally more efficient and economical (and in many cases safer) than in-person appointments, there are some things that are challenging to accomplish on a remote basis. From a diabetes standpoint, this includes:

  • Checking the skin for overused injection sites
  • Learning how to use medical devices (especially for the first time)
  • Examining the thyroid gland and lymph nodes
  • Evaluating glucose data (unless you can download and transmit data to your provider)
  • Performing a professional foot exam
  • Listening to the heart rhythm and feeling peripheral pulses
  • Checking for signs of neuropathy and retinopathy
  • Measuring vital signs (unless you have equipment for doing so at home)

The Logistics

Virtual care can be provided in a variety of ways, ranging from a phone call to an email, text message or video conference. Video can add a great deal to the quality of a consultation, as it allows you and your healthcare provider to pick up on body language and other visual cues. It also permits demonstrations (such as how to estimate a 1-cup portion of food), evaluation of your techniques (such as how to insert a pump infusion set), and use of a marker board for demonstrating complex subjects (such as injection site rotation or how certain medications work).

When using video, it is important to have access to high-speed internet. A computer is almost always better than a phone for video appointments, as the screen is larger and has better resolution. If you have the ability to download your diabetes data, do so and share access with your healthcare provider a day or two prior to the appointment. It may also be helpful to share some of your “vital” signs at the time of the appointment – a thermometer, scale, and blood pressure cuff are good to have at home.

In many cases, care provided on a remote/virtual basis is covered by health insurance at the same level as an in-person appointment. This applies to public as well as private health insurance. However, some plans require your provider to perform specific functions during the consultation (such as reviewing glucose data) in order for the appointment to qualify for coverage. Best to check with your healthcare provider when scheduling the appointment to make sure the virtual service will be covered. At our practice (which is 100% private-pay), virtual and in-person services are charged at the same rates.

If security is of the utmost importance to you, virtual care may not be your best option. Although there are web-based programs and apps that meet HIPPA guidelines, there really is no way to guarantee who has access to your information at the other end. My advice is to weigh the many benefits of virtual care against the (minuscule) security risk that virtual care poses.

Optimizing the Virtual Experience

Just like in-person appointments, virtual care can be HIGHLY productive if you do a little bit of preparation.

  • Do yourself and your healthcare provider a favor and download your devices, including meters, pumps, CGMs, and any logging apps you may be using, prior to the appointment. If you don’t know how to download, ask your healthcare provider for instructions, or contact our office… we can set up a virtual consultation and show you how. If you have not downloaded your information before, don’t be intimidated. It is easier than you think. People in their 80s and 90s can do it. Oh, and look over the data yourself before the appointment so that you can have a productive discussion with your healthcare provider.
  • Be prepared with a list of your current medications, including doses and when you take them. Check before the appointment to see if you need refills on any of your medications or supplies. If you take insulin, have all the details available: basal doses (and timing), bolus/mealtime doses (and dosing formulas if you use insulin:carb ratios), correction formulas (for fixing highs/lows), and adjustments for physical activity.
  • Try to get your labwork done prior to virtual appointments. This will give your healthcare provider important information about how your current program is working.
  • To enhance the quality of the virtual meeting, do your best to cut down the background noise (TV off, pets in another room, etc…) and distractions (get someone to watch the kids). Use of a headset may be preferable to using the speakers/microphone on your phone or computer, especially if there is background noise or you have limited hearing.
  • Use a large screen/monitor so that it will be easy to see details and do screen-sharing. And use front lighting rather than rear lighting. When the lights or window are behind you, you may look more like a black shadow than your beautiful self. “Ring” lights are popular for providing front-lighting.
  • Provide some of your own vitals if possible – weight, temperature, blood pressure, current blood sugar. This is important information that your healthcare provider can use to enhance your care.
  • Prepare a list of topics/questions that you want to discuss. Ideally, write them on paper so that you can take notes during the appointment. If there is a great deal of detail covered, ask your healthcare provider to send you an appointment summary by mail or email.
  • Be in a private place that allows you to speak openly and show any body parts that might need to be examined – including your feet and injection/infusion sites.
  • Be a patient patient! Technical issues can sometimes happen. It is perfectly fine to switch to a basic phone call or reschedule for another time.
  • Courtesy. Be on-time for your virtual appointment. If you are delayed, call your healthcare provider’s office to let them know. And if you are not sure how to login or use the video conferencing system, call your provider beforehand for detailed instructions. This will help to avoid delays. Have your calendar handy so that a follow-up can be scheduled right away. Oh, one other thing: Try not to be eating during the appointment… it is distracting and a bit rude. However, treating a low blood sugar is always permissible!

If there is one thing we’ve learned during the pandemic, it’s that virtual care is a win-win for just about everybody. Expect it to grow in use long after the pandemic. In-person care will never go away completely, but for treating/managing a condition like diabetes, virtual care has a lot to offer… especially if you use it wisely.

Note: Gary Scheiner is Owner and Clinical Director of Integrated Diabetes Services, a private practice specializing in advanced education and intensive glucose management for insulin users. Consultations are available in-person and worldwide via phone and internet. For more information, visit Integrated Diabetes.com, email sales@integrateddiabetes.com, or call (877) 735-3648; outside North America, call + 1-610-642-6055.

Source: diabetesdaily.com

CGMs to “Hack” Your Blood Sugar? People with Diabetes Speak Up

It’s becoming more and more common: whether in a coffee shop in Silicon Valley or in a weightlifting gym in Boulder, Colorado, people without diabetes are using continuous glucose monitors (CGMs) to “hack” their blood sugars, lose weight, and hone their diets accordingly. This article will explore the use of CGMs in the non-diabetic population, what the backlash from the diabetes community has been, and what the call to action should be.

CGMs for More Than Just Diabetes Management?

According to one website that promotes the use of CGMs in a non-diabetic population,

“ Wearing a CGM can facilitate the effort for someone who wants to hack their diet, blood sugar control, and overall health. This technology can go beyond a single blood sugar reading that a blood glucose meter provides. A CGM can provide real-time insight on whether blood sugar is trending up or down.”

What may seem like an innocuous accessory for the upper-class elite has many people with diabetes enraged. CGMs are crucial in providing regular, near-constant blood glucose readings to track time spent in range (TIR), identifying patterns in blood sugars, and anticipating both low and high levels.

The Original Purpose of a Continuous Glucose Monitor

For people with diabetes, they are life-saving, and more and more often are being coupled with insulin pumps that will then increase or suspend insulin according to the blood sugar that a CGM reads. It almost entirely eliminates the need for manual finger testing and has proven to help lower HbA1c levels, reduce dangerous low blood sugars, increase time in range, prevent unnecessary emergency room (ER) visits, and save the health care system money and save many lives. It has quickly become a necessity for tight diabetes management in recent years for many people.

For something so seemingly necessary for most people with diabetes, it clearly isn’t seen that way by industry: 16 states, including California (the most populous), do not have Medicaid coverage for continuous glucose monitors at all. And while most private health insurance plans (and even Medicare) now cover CGMs, affording one without health insurance is nearly impossible: the most popular CGM and the one that most commonly connects with insulin pumps, the Dexcom CGM, costs thousands of dollars out of pocket per month without insurance.

So when someone with diabetes, who is already struggling to afford their insulin, goes to the local coffee shop and overhears two dudes from Crossfit comparing their (perfect) blood sugar readings on their respective CGMs over their non-fat decaf lattes, the inequity of the situation can be enough to make your skin crawl.

Clair from Illinois says,

“The general population using CGM devices trivializes them.”

Cate from Nebraska adds,

“It absolutely incenses me [when non-diabetics use CGMs]. There’s a local doctor in my area who treats patients for weight loss and gives everyone a free CGM; meanwhile, it’s an arm and a leg to refill my own.”

Bonnie from Minneapolis says,

“It drives me absolutely bananas.”

We Are All Just Products of the System

Managing diabetes with a continuous glucose monitor is life-changing, but it is expensive, and living with diabetes in America is anything but easy. We have the most expensive insulin prices in the world, health insurance isn’t compulsory or cheap, and even when you do have a job that has health insurance, necessary diabetes technology is sometimes not even covered or affordable under your plan.

Seeing people use technology that we need can be seen as a slap in the face, but we’re directing our anger at the wrong place. The problem with accessibility in the United States is not a supply issue. The problem with accessibility in the United States is that we use health care as a commodity when it is not. We put health care into a capitalist box when it’s something that should be treated as the human right it is. We’ve priced people out of their lives. We treat things like insulin and insulin pumps and continuous glucose monitors as if they’re elastic goods when they’re 100% inelastic. We cannot negotiate our own pricing for insulin. We can’t haggle down the price or walk away. We need the drug or we die.

People without diabetes see products like continuous glucose monitors as the valuable goods they are and are willing to pay for them. No person who uses a CGM recreationally has it covered by their insurance, and it’s important to remember that.

It’s not a zero-sum game where someone’s CGM that’s paid for out of pocket in San Francisco precludes another person on Maine’s Medicaid program from accessing one of their own, but it feels like it does. Instead of taking our anger out on the gym-rat in Colorado who’s paying thousands of dollars out of pocket for their Dexcom each month (which is stupid, but why question their motives?), we should be angry at the government and systems that created this situation to begin with.

If the United States had a single-payer health care system where everyone who lives here had health coverage, we wouldn’t care what people buy on the free market. If all plans (including Medicaid!) covered CGM use for people with diabetes at 100% of the cost, it wouldn’t bother us what anyone else was doing with their blood sugar levels (diabetic or not). It’s a symptom of a system that denies people with diabetes the proper care and regular, reliable access to proper durable medical equipment that makes them covet these devices as much as we do. There’s nothing inherently wrong with people without diabetes using CGMs, but it does sure feel like there should be. 

CGM for non-diabetic population

Photo credit: iStock

Some People Support Wider Use of CGMs

In speaking with others for this story, I found several people who encourage non-diabetics to use CGMs, like Mindy, a registered dietician from Colorado,

“I am pleased that there is adequate supply for people without diabetes who can view the real-time movements and fluctuations of blood glucose. The more understanding there is in groups of non-DMs, maybe we can finally change the direction of people diagnosed with (type 2) in the future.”

Christie, from California, added,

“being mad about someone having a CGM that they bought on the free-market is similar to someone with hypertension being angry over another person having an at-home blood pressure monitor. It just doesn’t compute.”

In a country with nearly 100 million people living with prediabetes, learning to respond to blood sugar trends and figuring out which foods work best for your body can only be a good thing. And although it hasn’t happened yet, the more “mainstream” these devices become, the more affordable they’re bound to become, which would be great for everyone. Additionally, for shy diabetics, CGMs becoming more mainstream can also take away the stigma of having a visible device on your body 24/7. It’s suddenly “cool”.

Benefits for Everyone

Whether or not you have diabetes, a continuous glucose monitor can help with several things:

  • Learning how your body responds to certain foods (grapes versus crackers, for instance)
  • Identifying blood sugar patterns around mealtime and exercise
  • Diagnosing diabetes before the onset of ketoacidosis (DKA) in people at high risk (people who are overweight, obese, live with prediabetes, or who have the antibodies for type 1 diabetes)
  • Improving blood sugar to help maximize energy for a workouts
  • Helping people lose weight by managing their hunger (which is the result of fewer blood sugar fluctuations throughout the day)

In a country where over 70 million adults are obese and another 99 million are overweight, having more data regarding how our bodies respond to the foods we eat is vital. We have a type 2 diabetes epidemic on our hands that is only getting worse, and wider CGM usage may help curb that, but people need to be careful.

Using them as “wellness gimmicks” may bombard those who truly do not understand the relationship between glucose and blood sugars, leaving users overwhelmed with data and confused, while not making any dietary changes at all. In a true market economy, the greater the demand, the more competition will spring up, the more prices will fall (for both people with and without diabetes).

The real issue that people need to focus on is making sure that everyone with diabetes who wants a CGM can get one, but people without diabetes accessing CGMs on the open market will not prevent that from happening. We need to push for greater coverage for CGMs on the private and public health insurance market with our elected officials and make sure that we inch ever closer to the illustrious universal health care system that other industrialized countries enjoy. We need to make sure that everyone with diabetes has access to affordable insulin, pumps, and supplies (including CGMs), with strong grassroots advocacy to equip people with all the tools they need to thrive. If we achieve universal health care maybe someday everyone who truly needs a CGM can get one, but until then, let the Crossfit bro with his Dexcom sensor alone. Although you can let him know that the caffeine in his latte will raise his blood sugar a few points in the meantime.

Source: diabetesdaily.com

How Racial Bias Impacts Health Outcomes

COVID-19 is killing black Americans at three times the rate of white Americans. But it is not just COVID-19. Four hundred years of systematic discrimination has created systems that leave black people with dramatically worse health outcomes than others. Many living with diabetes have faced discrimination in their lifetime. Diabetes still poses barriers to getting fair treatment in our society, whether in school or work, exclusion from sports teams, or mismanagement in the hospital setting. All too often, living with diabetes as a person of color will compound these barriers.

Studies have shown that there are systemic, negative biases against people of color embedded in our healthcare system. This is layered on top of inequitable social determinants of health that people of color face, leading to poorer health outcomes, additional complications, and earlier deaths.

Black People Have a Higher Rate of Diabetes

Black people are more likely to have diabetes. There are 4.9 million non-Hispanic African Americans aged 20 years or older who have diabetes in the United States, according to the CDC. They are 77% more likely to have diabetes than non-Hispanic Caucasians. Part of this trend may be genetic, but one’s environment and socioeconomic status play a significant role in the development of type 2 diabetes, especially in a society without a robust social safety net.  Among racial and ethnic groups, African Americans have the highest poverty rate at 27.4% (compared to Hispanics at 26.6% and whites at 9.9%). Additionally, 45.8% of young black children under the age of 6 live in poverty, compared to 14.5% of white children.

There are many factors that contribute to this, but a history of institutionalized racism (the legacy of slavery, redlining and Jim Crow laws) have largely prevented African Americans from cultivating intergenerational wealth (which for most Americans comes from buying and selling real estate), and breaking the cycle of poverty proves to be nearly impossible in most circumstances.

Poorer, segregated (de facto segregation) black neighborhoods are more likely to face food deserts (areas where there are few or no grocery stores), lack access to healthy foods (including fresh fruits and vegetables), families may lack access to reliable meals (especially in the summer, when schools are no longer serving children breakfast and lunch), and unsafe streets and a lack of green space (few or no public parks). Neighborhoods of lower socioeconomic status are all risk factors for obesity and the eventual development of type 2 diabetes. 

Black People Have Higher Rates of Complications and Death

Black children and families are more likely to develop diabetes, and when they do, they face graver health outcomes. One recent study found that black youth have an average HbA1c of 10.6% compared to 8.3% for their white peers, and black children are twice as likely as white children to die from diabetes. Blacks are also more likely to experience greater disability from diabetes complications such as amputations, blindness, kidney failure, and increased risk of heart disease and stroke. Diabetic retinopathy is 46% more prevalent in African Americans than non-Hispanic whites, and African Americans are at least 2.6 times more likely to have end-stage renal disease due to diabetes than Caucasians. Most telling: the premature death rates for blacks with diabetes are 27% higher than for whites with diabetes.

racism and diabetes

Photo credit: iStock

Racism Is Built into Our Healthcare System

Implicit bias plays a large role in the unfair treatment of black people in the health care setting. In 2005, the National Academy of Medicine released a study that found that “racial and ethnic minorities receive lower-quality health care than white people, even when insurance status, income, age, and severity of conditions are comparable.” This suggests that poverty and lower socioeconomic status does not account for the whole picture of poorer health outcomes in black people with diabetes.

The report continued, “…minority persons are less likely than white persons to be given appropriate cardiac care, to receive kidney dialysis or transplants, and to receive the best treatments for stroke, cancer, or AIDS. It concluded, “some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care.” Simply put: people are dying at higher rates just because the color of their skin is darker.

One study of 400 hospitals in the United States showed that black patients with heart disease received older, cheaper, and more conservative treatments than white patients presenting with the same disease and symptoms. Black patients with diabetes have higher rates of amputations than white patients, even when less invasive interventions are available. Additionally, another study showed that physicians were more likely to prescribe pain medications to white patients, mistakenly believing that black people “feel less pain”.

COVID-19 is killing black Americans at three times the rate of white Americans.

Where Do We Go from Here?

Social determinants of health, physician and healthcare workers’ implicit bias and systemic racism in our healthcare system all contribute to higher rates of disease, complications, and death. Neighborhoods and schools remain dramatically segregated and unequally funded.

The United States has a two-tiered health care system that provides fantastic care to those who can afford private health insurance, and little to none to those who cannot (aside from Emergency Department visits). We, as a society, do not value or fund preventive health care as much as we should. We don’t prioritize feeding our babies healthy food, or making sure they have space and safety to exercise regularly. We step in with too little too late for those who need help the most. We are biased in our healthcare decisions and have not fought against institutionalized racism early or long or loud enough. Now is not the time to “not be racist”, but to actively dismantle institutionalized racism from the inside out.

We need more black physicians, and nurses, and emergency medical technicians. We need to put our dollars into segregated neighborhoods and schools and prevent diabetes before it devastates underserved communities even more. We need to listen to black patients in hospitals. We need to trust black people when they voice their health concerns. We need more black voices in the diabetes online community. We need to lift up the voices of black people.

We need to do more for those that we have failed for far too long. We have already lost so much, and we need to act before it is too late.

Source: diabetesdaily.com

Centralized Healthcare: Is It Best for the Patient?

There are many ways that a healthcare system can operate. The type of system that is best suited for a population may be dependent on many factors, including the population size, demographics, and various other economic, political and cultural considerations as well. 

Here we discuss some potential approaches to healthcare system organization and major considerations in health care reform. In large, because healthcare is a service that is paid for, the specific payment model represents a large consideration in the way the system works. Another big consideration is whether the services are paid for publicly or through private enterprises (like private insurance companies). Additional “middle-men”, such as pharmacy benefit managers (PBMs), health insurance companies, supply manufacturers and distributors, etc. can further complicate both price-setting, health care delivery, and patient outcomes. 

Many different countries have elected vastly different ways to govern health care. Some, like the UK, rely on a more centralized (public) model to deliver care and services, whereas others, like the US have historically relied more on privately funded providers and health services. In many cases, specialized entitlement programs (like Medicare and Medicaid) that are subsidized by the US Government can help specific patient populations gain access to the services they need at an affordable price. Also, although there are federal guidelines, in the US, states can also enact specific legislation to help people living in their state, by having specific state-run programs for the retired and low-income, as well as policy changes, like co-payment caps on state-regulated health plans for prescription medications like insulin. 

To Centralize… Or Not?

Some hail the benefits of a centralized, one-for-all, affordable, publicly-funded health care system (also referred to as a single payer system). After all, affordable and quality health services are a cornerstone of our well-being as a society. One of the biggest concerns brought about by critics is the lack of competition this could create, resulting in potentially fewer available resources (e.g., providers, supplies, services) and poorer quality of care as a result. In addition, this can also translate to longer wait times to receive health care services. 

As many individuals continue to struggle to afford health care in the US and other parts of the world, more people are pushing for a more comprehensive, centralized public health care system that could provide affordable services to more people. 

Current Payment Models Shape Outcomes

A large factor within a healthcare system is what the payment model to the providers looks like. An expert summary by the MMA Work Group to Advance Health Care Reform explains that there are several main models, each with its potential pros and cons. 

The fee-for-service payment system is one where reimbursement to the providers corresponds directly to the specific services rendered. This is the primary model that is used in healthcare models in the US. One major problem with this system is that getting reimbursement for each service or treatment can create a conflict of interest for providers, resulting in the potential to overtreat patients, losing focus on patient wellbeing, including preventative strategies. Also, this may limit comprehensive care for patients, as different providers may be less likely to coordinate care. On the other hand, this model can encourage productivity. It also offers a relatively direct way of reimbursement for various services. 

On the opposite side of the spectrum, capitation, refers to a carefully managed coordination of reimbursement for services. American College of Physicians explains:

Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. The actual amount of money paid is determined by the ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided. Capitation rates are developed using local costs and average utilization of services and therefore can vary from one region of the country to another. In many plans, a risk pool is established as a percentage of the capitation payment. Money in this risk pool is withheld from the physician until the end of the fiscal year. If the health plan does well financially, the money is paid to the physician; if the health plan does poorly, the money is kept to pay the deficit expenses.”

This type of model may allow for more flexibility with respect to care delivery, including potentially more innovative and effective services. It may also allow for more collaboration between providers and benefit patients due to potentially shifting more focus to eliciting overall well-being as a goal. On the other hand, setting up this type of system is a complicated and arduous process, and may also limit access for high-risk patients, and possibly reduce patient options, including the providers and services available to them. 

There are multiple variations of coordinated payments within this broad spectrum, and more proposals are continuously being drawn up by various organizations. Some examples include pay-for-coordination, pay for performance, bundled payments, and various forms of comprehensive care.

Importantly experts warn of the potential effects of these systems on patients, as illustrated below –

Opinions Vary

What kind of system will work best to serve the public in a timely manner without sacrificing quality, while also being affordable? The verdict is still out, and there will likely never be a consensus. Lessons learned from different countries, and on a more local level, will likely continue to shape the dialogue and direct (typically slow-moving) policy changes. 

Some feel strongly that universal healthcare is a right, and not a privilege. Others worry that such a system will decrease the quality of services, increase wait times, and thus negatively affect the patients and their health outcomes. Some believe there is no one-size-fits-all, and that specific systems must be driven from the ground up at a very local level. 

***

What do you think? How is healthcare organized where you live and do you think it is an effective model? How do you think policy has affected your diabetes-related care? How do we go about effecting significant policy changes, when and where they’re needed?  

Source: diabetesdaily.com

Prior Authorization: Getting Diabetes Supplies and Medications Covered by Insurance

This content originally appeared on diaTribe. Republished with permission.

By Divya Gopisetty

What is a prior authorization? Read on to learn more about why diabetes supplies or medications might require a prior authorization and how to go through the process

It can be frustrating to learn that you need a prior authorization when you already have a prescription. Insurance plans sometimes require a prior authorization to cover a diabetes supply, device, or medication, even if your doctor prescribed it to you.

Read on to learn about what a prior authorization is, and how you can make the submission process as smooth as possible.

In this article:

Click to jump to a specific section!

What is a prior authorization?

My pharmacist told me I need a prior authorization. What happens next?

How can I check if I need a prior authorization?

How long do prior authorizations last?

What happens if the prior authorization is denied?

What is a prior authorization?

A prior authorization, also known as a pre-authorization or pre-certification, means that your healthcare provider or device company has to get specific approval from your health insurance company (so that it will pay for it).  The requirements for prior authorization differ between and within insurance plans.

If you need a prior authorization, the pharmacist cannot process your prescription until your healthcare professional has contacted the insurance company. Similarly, a device company may not ship your diabetes device to you until it has prior authorization from the insurance company.

A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary. Before your insurance plan will cover a certain device or drug, you must show that you meet a set of criteria.

Prior authorizations are most often handled by your healthcare professional’s office, but sometimes are handled by the device company itself (e.g., for CGM).

If you want to see what a prior authorization request form looks like, check out this one for OptumRx.

My pharmacist told me I need a prior authorization. What happens next? 

  1. If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional.
  2. The healthcare professional will contact your insurance company and submit a formal authorization request.
  3. Your insurance plan may have you fill out and sign some forms.
  4. Your insurance plan will contact the pharmacy once it has approved or denied the request.

During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information. Prior authorizations usually take about a week to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy.

If it wasn’t approved, your pharmacy should be able to tell you why, and then you can decide to request an appeal.

As someone living with diabetes, you are your best advocate. Be prepared to track down the paperwork to make sure you receive the requested device or medication.

How can I check if I need a prior authorization?

Check your health plan’s policy and formulary (you can normally access these on the insurance company’s website) to see if any of your treatments require a prior authorization. Or, you can call the member services number found on the back of your insurance ID card to speak with someone directly.

How long do prior authorizations last?

Most approved prior authorizations last for a set period of time (usually one year). Once it expires, you’ll have to go through the prior authorization process again.

What happens if the prior authorization is denied?

  • You can request an appeal (which is often successful!)
  • You can pay the full cost for the medication or healthcare supply, without insurance coverage.

Want to learn more?

Check out this easy-to-read resource created by DiabetesSisters on prior authorizations, step therapy, and appeals.

What’s Worked for Other People with Diabetes? Hear from Them!

  • I was denied my first CGM in 2008 by a Blue plan and fought and won by knowing how to Google my payer’s medical policy and prove that I met coverage criteria. It helped that I was given the HCP line phone number by a nurse sympathetic to my cause, but I ended the call with an authorization code. – Melissa
  • My strategy has always been persistence pays (eventually the insurance company will give in, although they may have peculiarities to navigate. The doctor’s office is really key and many have specialists who only deal with insurance company issues [mine does]). I’ve been covered by 4 insurance companies over the past decade while at the same employer if that tells you anything about the evolving insurance market. My experience with Anthem was a hassle but predictable, United Healthcare was easiest to navigate, Aetna was straightforward but a pain and had some weird rules (Why does a precertification inexplicably expire at the end of a calendar year? My chronic illness did not expire at the end of the year.). – Scott
  • Do you have experiences with prior authorizations? Let us know!
diaTribe Series

Image source: diaTribe

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

Can Continuous Glucose Monitors Help Change How We All Eat?

If you share with someone results from a study indicating that even “healthy” people often eat foods that cause harmful blood sugar spikes, they may believe you and understand the underlying reasons. However, they may be much more likely to act on this knowledge if they wear a device that shows them in real time […]
Source: diabetesdaily.com

Search

+