A general warning to any practices that purchase drugs administered to patients and then bill the patients’ health insurance for reimbursement. We have recently seen United Healthcare deny certain drugs for “no authorization on file” despite the practice’s pre-authorization inquiry confirming that no authorization is required for the specified drug. It seems that the “loop hole” being employed by UHC is that the practice did not specifically ask about the “buy and bill” allowance for the given drug. In these cases, UHC requires the drugs to be obtained through the patient’s pharmacy benefits – in which case there is no pre-authorization required. However, the same UHC policy does not allow benefits for these drugs when purchased by the practice and billed to the patients’ health insurance policy. Despite our attempts to appeal / object to the misleading (and lacking) information provided by the UHC pre-authorization department, UHC has stood firm that there was no “misquote” regarding the coverage on these drugs due to the fact that the practice did not ask about the buy and bill coverage (UCH is accepting no responsibility to be forthcoming with that key piece of coverage detail when the practice had initially inquired about a pre-authorization).
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