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Certificates of Medical Necessity


Not too long ago I got a letter labeled “URGENT” in my mailbox at work.

The letter was from Walgreens regarding a patient I had seen several weeks earlier. I cut and pasted parts of the letter to make it fit on one page above.

As the prescribing physician, in order for our government to pay for the prescription I wrote for the patient … several weeks ago … I had to sign a statement stating the following:

“I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for this patient’s well being. In my opinion, the supplies are both reasonable and necessary to the accepted standards of medical practice in the treatment of this patient’s condition and are not prescribed as convenience supplies. By signing this form, I am confirming that the above information is accurate.”

Seriously? To get reimbursement for a medication on the $4 list, the government is forcing health care providers to take the following steps:

A pharmacist has to receive the denial from Medicare, look at the medication, enter all the information into the CMN and generate a letter to me. The pharmacy must then spend 44 cents to mail the letter to me
Once I receive the letter, I don’t remember the patient, so I am then forced to waste time looking up the patient’s chart, reading through it so I could find the diagnosis and make sure that the flipping $4 albuterol prescription wasn’t for the patient’s “convenience.”
The pharmacy then spends another 44 cents for the self addressed postage paid envelope.
Once the pharmacist receives the certificate saying that the patient really does need his albuterol solution, he then has to spend more time going back on the computer, matching the signed statement with the visit and then forwarding the claim onto the government for medication that has already been dispensed.
Then the pharmacy waits months and hopes that it gets back $3 in reimbursement for a $4 medication.

In essence, health care providers waste 50 times as much value in time getting paid for something after the fact than the item is worth. And the government knows it. It is just hoping that one of the providers won’t do all the paperwork so that someone else gets stuck paying for the medication – other than the government. No paperwork, no payment.

Is this what medicine has come to? Harassing providers so much with pre-authorizations and post-authorizations because they don’t have enough to do? What other ways can we concoct to steal services and supplies from medical providers?

Then I thought that since the government uses these authorizations so much, that they must be a good idea.

Before I send in my next tax payment, I’m thinking about sending in a similar authorization to the IRS.

“I, the undersigned, certify that the above tax payments are necessary for this country’s well being. In my opinion, the government purchases made with this money are reasonable and necessary to the accepted standards of accounting practices and are not spent on wasteful or potentially wasteful projects or items. By signing this form, I am confirming that the above information is accurate.”

Any accountants out there? Would this work?


  1. I read this article and thought of all your posts on the costs of the paperwork that goes into being a doctor. I did not realize that close to 2/3 of the cost of practice was eaten up that way (at least for this particular doc)!!

  2. Did that form come attached to the FMLA paperwork as well?

  3. Not sure if it would work (I wouldn’t hold my breath), but it *would* show you have titanium nerves and balls of steel!

  4. Enforcement is often expensive. The fact that enforcing of regulations may cost more than the actual medication is only interesting if a) prescriptions were never being misused by physicians or b) even if they were, auditing and enforcing would be futile or c) there are much more efficient ways of enforcing than burdening doctors and pharmacies with paperwork.

    It seems unlikely that the follow-up to pharmacy and physician is just random. Rather it’s likely that SOME physicians are prescribing OUTSIDE best practice guidelines, and yes, for “convenience.”

    It also seems likely that some method of enforcement to reduce unnecessary and unjustified costs is proper. The real question is how to do it.

  5. Most physicians write many prescriptions daily. Medicare, Medicaid and other insurance companies don’t even bother to check the patient’s diagnosis before automatically kicking back “prior authorizations” to the physician.

    The amount of time that is wasted in
    1. pulling the chart
    2. matching it with the request
    3. checking to see when the prescription was written and why
    4. filling out the diagnosis and codes (which the insurance company already has if the claim for the visit was submitted)
    5. signing the form
    6. Making a note in the chart that you have done this
    7. faxing the form
    8. filing the form in the appropriate place
    9. refiling the chart
    10. doing this all again when the insurance company or pharmacy says they didn’t receive this the first time…..

    AAAARGH – for this I went to school 12 years after high school?

  6. Here’s an example of “Just a Medicine Refill” from my blog.
    Got me started thinking.

  7. Where do you buy stamps at? They cost me 48 cents.

  8. I have to say coming from the other end (the pharmacy) that getting all the crap for prior auths isn’t fun for us either especially when I have the patient pissed because XYZ insurance or medicaid won’t cover some medication. At least if the script the insurance wants a PA from is a PCP or specialist the person is seeing chronically then it doesn’t cost us much to fax a form over basically saying the insurance wants a PA, if you want to try and get one then here is the number to call. ER docs, hospitalists, and residents we don’t even bother with as it is a waste of our time and their time. I had to laugh one time when a patient demanded we call the resident to get a PA, the resident actually asked me: what a prior auth was and how long the pharmacy would take to get it filled out. He changed his tune for wanting brand name XYZ after learning that it was his duty to fill it out, not the pharmacist or pharmacy’s job. I also remember one patient getting cymbalta from a hospitalist because her previous rx had run out and was pissed state medicaid was not covering it without a PA, she seemed to think the hospitalist was going to whip up the PA at 7pm on a friday night so she could get the med right then and there, like that is going to happen; I think not.

  9. I’m a recent accounting grad with a job as a junior bean counter and oh how your analogy makes me laugh! Though, if I start to get these statements with the tax forms I send out I won’t know whether to laugh harder or sign them with an illegible scrawl and mail them back…

  10. As an accountant’s spouse and office manager, and veteran, you have no idea! :) The way that all gov’t agencies operate is based on over-regulation and overlapping. It’s insane. Their budget processes suck and in any private business, whom ever would operate that way would fold in no time flat. It amazes me that people cannot understand how their tax dollars are spent and the absolute lack of fiduciary responsibility the government shows.
    Not only that, but I KNOW that time equals money in our business and gov’t workers constantly pull the teat and when they’re done, they’re done. No late hours, no busting tail, no thinking required…not all… but the vast majority. And heaven help the out of the box thinker who finds a new more efficient way to do something…they’ll just waste the saved money on another redundant arm of consumption. Okay…getting off the soap box.

  11. Hey, this is what it costs to prove that you aren’t denying his Oxycontin script just because he’s black.

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