A patient came to see me for a “well visit” and one of the issues that came up was tobacco cessation. After dealing with a few patients who came in for similar reasons, I have decided not to code for tobacco cessation visit, unless I specifically know that the payor covers it or if the patient has Medicare.
I prescribed Zyban, which was not covered. Initially, the pharmacy and I were told that it was “non-formulary” . I switched to Wellbutrin SR and was subsequently told I needed to get prior authorization for the patient. Before going through the hurdles, I had already realized that the patient probably had no coverage for smoking cessation, but I could technically get the medication covered for behavioral health reasons. Of course, this is what turned out to be the case.
The patient requested that I get the medication authorized again for behavioral health reasons, she was informed by her insurance that they would cover it. I told her no. My reasons? Heaven forbid she has a seizure or some other adverse reaction to the medication, then some sleazy lawyer and subsequently her insurance company would be all over me for “authorizing a medication under false pretenses”.
It’s just a shame that we, as caring providers, have to jump through these hoops and end up being scapegoated. The patient probably thinks that I’m just being difficult, but in reality, I am just protecting myself. The issue, dear patient, is not with me, but the coverage that your insurance provides. Without putting too much blame on the patient (this is more about the payors), look into your coverage prior to selecting the package. It’s not always about saving the most premium dollars. You get what you pay for. Before selecing a package, look into the particular coverage and ask which insurances cover it. For example, if you need counseling, make sure your insurance has good out of network behavioral health benefits. This is especially important in Manhattan, since most therapists don’t accept medical insurance. This way, you will get about 50% back from your insurer.
