Suing to be paid for prior authorizations

Hopefully this will set a precedent:

Gary Gibson, FACP, sued MEDCO Health Solutions of Columbus North, Ltd., in Trumbull County Court to collect on the time he spent filling out two or three prescription inquiries a week, each taking between six and 10 minutes to complete. He told MEDCO in December 2005 that he would bill $150 an hour to fill them out, and when MEDCO said they would not pay, he sued in 2006.

The courts decided March 6 of this year that MEDCO’s prescription inquiries were designed to examine whether the prescriptions were the most economical for MEDCO, and since they were solely for MEDCO’s benefit, Dr. Gibson could collect payment for his time.

Here is the court’s decision.

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  • Ian Furst

    We have the workmen’s compensation board up here. I’d love to do the same thing as they are notorious for being difficult to coordinate billing through.

  • Anonymous

    he got 187.50. i wonder how much it cost him to pursue this?

  • Anonymous

    I think the insurer should be entitled to a jury made up only of health insurance claim reps. It’s not fair that laymen get to judge them.

  • Anonymous

    What a frivolous comment.

  • Anonymous

    What does my wife (a patient/victim) get? She gets her refill delayed for a few days without any advance warning. They do this when the pharmacist tries to authorize a refill when, in fact, they could easily do it by mail to the doctor without delaying the patient’s refill at all. Three days here, three days there, and pretty soon the insurance company has cut its costs a couple of percent buy withholding medication.

  • Anonymous

    I don’t think you get a jury for a 200$ claim. That would be quite an imposition on the jury pool. It really isn’t controversial at all. You want a service from a professional, you pay for it. The only reason that it is somewhat controversial is that the medical profession have conditions others under a variety of circumstances to expect something for nothing by poor business practices.

  • Anonymous

    He will receive no money, but on his deathbed he will receive total consciousness. So he’s got that going for him. Which is nice.

  • RJS

    Anon 8.06 clearly has no idea how PAs work. Blaming the pharmacist or the doctor for the way the system is. It’d be hilarious if it wasn’t so common. (And stupid.)

    RE: this doctor. Rock on, dude!

  • Anonymous

    “he got 187.50. i wonder how much it cost him to pursue this?”

    That’s so not the point. What happens now is that this doctor can charge a fee going forward in the future for every MEDCO request and probably has reasonable grounds to request payment from other companies as well. Its all about establishing the precedent, not getting the $187.

    My office probably sees 1-3 requests like these come in every day. No, they’re not all from the same company and I wouldn’t know exactly how many of the hundreds (thousands?) we complete every year are for MEDCO, but the ability to charge $50 or $75 going forward for each one would certainly add up to thousands of dollars each year.

  • Anonymous

    “I think the insurer should be entitled to a jury made up only of health insurance claim reps. It’s not fair that laymen get to judge them.”

    This was not a jury trial; it was a judge’s decision. Obviously we know where you’re going with this, but I’d be happier to have one knowledgeable judge determining the outcome of a malpractice trial than a jury of 12 potential idiots.

  • Anonymous

    I don’t think anon 8:06 was blaming the doctors and pharmacists… sounds like his complaint is against the insurance company and their practices (rightfully).

  • Gary

    Dear Colleagues and Readers,

    Thanks for your interest. The quote from Bill Murray about receiving “total consciousness” on my deathbed was clever- we should all be so lucky.

    Pharmacy Benefit Management Companies are the illigitimate children of an affair between insurance companies and the pharmaceutical industry; they interrupt the interaction between the patient and the doctor (as well as the pharmacist) at the point of service with a remote control mechanism that is entirely wasteful, mercenary and redolant of what Enron did with distribution of energy. It is a perfect setup for corruption. If all PBMs were forced out of business today, everyone would be better off.

    I did not file this case against MEDCO to make money. I filed it to prove a legal point, which so far seems to have worked.

    The point is this: if a PBM not acting at the request or on behalf of the patient demands my time in order to fill out forms (for the enrichement of the PBM) authorizing the dispensing of my prescriptions, then a) it is obligatory for me given the PBMs privileged position, b) my time in complying with the “prior authorization request” is worth something more than nothing.

    This would only be suitable for class action status if every doctor in the suit was following evidence based medical principles, and giving appropriate consideration to patient safety first and of cost of the medications second when prescibing medications. When those conditions are met PBMs have nowhere to hide. On their death bed, PBMs might be dragged away by those little squealing creatures from the movie Ghost rather than receiving the blessing of total consciousness.

    This is a critical time for doctors in the U.S. If we do not stand up as patient advocates and resist greed and corruption, then we have little chance of transforming health BUSINESS back to health CARE. We are all ambassadors for a sacred profession. It remains sacred only if we permit our thoughts and actions to preserve it as such. We have more science and technology to draw from than any generation of doctors that have proceeded us, and that is a priceless gift we can share with our patients. In the 2000 report of the WHO, the U.S. ranked 37th among 193 member nations in quality of health care, but first in cost per capita. It is our fault to unless we work individually and together to mend a broken system.

    Gary R. Gibson, MD, FACP

  • Anonymous

    I’m anon 8:06 and I did NOT blame doctors or pharmacists at all. I’m sympathetic to both on this.

    I’m perplexed how my comments can be so misunderstood, but I’m not surprised. I’ve posted here before and gotten some similarly hostile reaction. It seems to me that there are doctor/readers here who are looking to beat up on any non-doctor who offers an opinion. It’s sad. I feel sorry for their patients.

  • feminizedwesternmale

    Medco @ 1800-837-0959

    Re Case Number: XXXXXXX

    We received your request regarding the above case. In accordance with case law Case No 06-CVF-106, Medco vs. Gary R. Gibson, M.D., F.A. (see adjoined), please remit $10 prior to consideration of further processing of your request. If we do not feel the services appropriate, this fee will be refunded. No action is necessary on your part.

    No further requests will be processed regarding this case number without the remittance, and will not become a part of the patient’s permanent record./


    M.A.Smith M.D. for LCIM

  • Anonymous

    “Obviously we know where you’re going with this, but I’d be happier to have one knowledgeable judge determining the outcome of a malpractice trial than a jury of 12 potential idiots.

    # posted by Anonymous : 10:02 AM”

    And when the judge rules against you, he’s an idiot again. You want immunity for yourself, not fairness.

  • Anonymous

    Praise, honor and admiration for Dr. Gibson!!!

    We need more doctors with your courage, intellect and conviction.

    Indeed, this cause needs to be a class action – it’s time for this enslaved profession to rise up…

    Thank you!

  • Anonymous

    I work in a Doctor’s office and we see about 6-10 PA requests a day. We spend 10min to 1.5hrs each, some of which they deny the first and up to the 3rd request. We are not the ones with the contract with the insurance company. It is the patients and it should be their responsibility to speak up against the insurance company. We do charge for PA’s or we give the info to the patient to have them contact their ins. Do you relize how much of our time is spent on these STUPID REQUESTS.??? Example- the patient has been on this medication for 5 years. This is a very common PA request for us. If a doctor is prescribing, then that means the pt needs this medication. This goes for ALL insurance companies.

  • Anonymous

    Question for “Anonymous 5:09 pm” You stated you charge for PA’s. Who are you charging and what do you charge? My physicians are looking for ways to charge for this very time consuming process as well. Physicians are doing more and more for less.

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