Representing People With Denied Insurance Claims

A nemesis for some insureds: pharmacy benefits managers

| Aug 13, 2019 | Denied Insurance Claims

It’s just “one more layer of bureaucracy,” says a disgruntled doctor.

That physician’s discontent – arguably, even rage – points straight toward a single participant in the health care system. Namely, that is the pharmacy benefits manager. So-called PBMs were largely nonexistent in the medical industry a few short years ago, but are now playing an increasingly key role as health insurance company adjuncts.

Their job: to weigh in on physicians’ prescriptions and make definitive judgment calls on whether they will be filled or rejected.

Understandably, that infuriates doctors. Those singularly trained professionals are the individuals who work most closely with patients. They have no doubt that their voice should reign supreme regarding needed regimens and drugs for the sick – and sometimes dying – people they treat. Legions of them say they are angered and stunned by the fact that far-removed and anonymous individuals who are not their peers can override their professional recommendations.

And yet that is precisely what PBMs do, with increasing frequency and often little accountability. A recent national media report on pharmacy benefits managers and their often unbridled powers terms them “elusive middlemen with the authority to deny doctors’ prescriptions based on company policies.”

To say that PBMs are deemed a flatly unwelcome addition in the health care realm by the nation’s physicians is a stark understatement. Doctors who comment on them criticize not just their intrusiveness into the patient-MD relationship, but the fatal consequences that can result from their ignorance and narrow focus on costs.

“They are hiding behind all these processes,” complains one practitioner, “and we are struggling here.”