The Pre-Authorization Runaround

If you've ever presented a prescription at the pharmacy only to be told that additional pre-authorization information is required by your insurer, you know that what usually follows is the pharmacy's offer to notify your provider of the need to contact the insurer.  And when you go back and you still are not able to purchase the prescription with insurance coverage, you will likely again have the pharmacy offer to contact your physician. 

If you follow up with your physician independently or your insurance company independently, you will get the distinct impression that — even though you are the person in need of the prescription and carrying the relevant health insurance — this is a conversation ordinarily meant to exclude you.  You may persevere anyway trying to interject yourself into a conversation designed to exclude you or you may rely on the representations of the pharmacy that messages are being sent and the representations of your provider's answering service that your messages are being received.  If you choose the latter, you may be surprised to learn you do so at your own risk. The legal message has been that the pharmacy owes you no duty to try to advance your claim or to help you document medical necessity within the terms of your plan.

And then, just a few weeks ago, along came Correa v. Schoeck out of the Massachusetts Supreme Judicial Court.  There, the court held that parents of a young woman with a seizure disorder who relied on the representations of the pharmacy could in fact sue Walgreen's for apparent failure to reach out to the provider's office and to follow up as was promised on several repeated visits. Noting that "[t]he skill and knowledge of pharmacists today involve more than the dispensing of pills," the court refused to dismiss the case.

Now we'll see what happens on the merits. What we do know already is that Marushka Rivera was a young woman with significant health care needs and that the last year of her life was very difficult indeed.

 

 

 

 

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