Thank you for joining me today today we’re going to look at a repatha denial and answer some questions about why in certain cases we can simply just get something approved without any additional information and while in similar situations that some people think are exactly the same we can’t really do anything about and that’s what today’s example is today is an
Example of a situation where there was really nothing that we could do but it’s very similar to other situations where we can simply just get it overturned without any additional problem and what we plan on doing at the end is showing how very small changes in the case situation can cause one pathway to be cheaper than another or more administratively effective
Is the terminology that i like to use and remember what our goal is is to take all this pharmacy paperwork and figure out how to deal with it in the cheapest way possible and by the end of this video you’re going to understand why this is the cheapest way of dealing with this issue in this example we have two denial reasons number one we need an ldl greater
Than or equal to 70 within the past 90 days secondly we need to trial the high intensity statin in combination with zetia or a reason they couldn’t use it the facts of the case are number one the ldl could not be calculated this is due to the fact that the triglycerides are over 400 their most recent lab would have been in date however they had triglycerides of
Over a thousand therefore it could not be calculated secondly they’re on a high intensity stat with receipt percent 20 milligrams however they are not currently on zetamine lastly their ldl goal is 55 milligrams a deciliter what’s on that screenshot there is that they’re a diabetic with a history of revascularization procedure and per the diabetic endocrinology
Guidelines they’d be considered extreme risk and they would recommend less than 55 so that’s not a problem the ezetimite is not a problem assuming that we can get a calculated ldl if it’s implausible that they would be able to get there to their goal of lesson 55 or even if we wanted to use our gold lesson 70 then that would be unreasonable for them to try so
Our main problem here is that we don’t have an ldl so we could have the patient go do a direct ldl or there’s another way to solve this problem some of the time we’ll talk about that on the next slide whether or not we can appeal this or not is really going to come down to whether we can get that calculated ldl so the reason that we can do it some of the time and
Not others is due to two different equations so the first equation is the ferdenwald equation i believe i’m pronouncing i hope i’m pronouncing that correctly and this is the standard equation that is used by most labs that do a calculated ldl the ldl is equal to the total cholesterol minus the chdo minus triglycerides divided by five and it is effective up to 400
Milligrams per deciliter that’s where that comes from there is however another equation that you can use called the samson equation and this is more accurate and it is effective up to 800 milligrams per deciliter so assuming the triglyceride level is let’s say 500 600 or 700 as long as we have all of these variables here the total cholesterol hdl triglycerides
And non-hdl then we can simply just recalculate it and now we have a calculated ldl once we have a calculated ldl we can then determine whether or not we need to meet our zettamide criteria and then from there we can simply determine if we can appeal or not in most of the cases we’re going to be able to do that appeal now that you have a little bit of background
About this specific case and the different tools that we can use to try to get things overturned you’ll be able to better understand our recommendations so for this case we’re going to recommend to not appeal and to perform a direct ldl the reason is is that the samsung equation would not be able to give us that calculated ldl as you recall from the beginning the
Triglycerides were over one thousand one hundred now if that were the only reason that it was denied we could st i would rec we would change the recommendation to appeal the reason is is that in this case since the ldl is goal is 55 and the total cholesterol is 260 or let’s say if you had a situation where it’s even higher than that there is a distribution curve
On that study where it would be highly implausible that their ldl would be under 55 or under 70. so you can there’s some other math that you can do and basically make an argument we don’t know what the ldl is but based on these distribution curves we could estimate that it is likely to be more than this number and that’s really what it’s about however in this
Case where we’ve got not only got the ldl but then isetimide well now you’d be doing an estimate of an estimate and once you start getting into that situation then your approval rate let’s say for the boilerplate argument where we don’t know what the ldl is and we’re using a distribution curve that would probably be about 70 percent but once you’re doing the
Estimate of the estimate it probably be 30 to 40 percent and that’s probably too low for it to be administratively effective so what we recommend here is to perform the direct ldl we only recommend that you would consider azedimide is in two situations if the patient will take too long to get back to you so if they’re going to take you know six months to get back
You may as well send it in or if it’s conceivable that the acetamide could get them to gold so if their ldl comes back as 60 and the goal is 55 well they’re probably going to need to try that in in most cases so the reason that we don’t recommend to try it in other situations is because if it’s not conceivable that it could get them to go let’s say their ldl
Comes back as 150 and the goal is 55 there’s no way that they’re going to be able to get there and in those situations it’s going to be overturned 99 of the time the only time it’s not going to be overturned is people who are being unreasonable the the reason for the administrative effectiveness is that if you send this for the patient to try it you’ve got to
Send the prescription sometimes you’ve got to send it to a certain pharmacy you got to call the patient they might have questions about the drug so you have to spend time doing that and once it gets to the pharmacy it could possibly need a product it doesn’t need a prior that often anymore but we do get them from time to time probably about 10 ish percent of the
Time even if it doesn’t need a prior off a lot of times this is on a tier 3 or it’s even more expensive which is about fifty dollars on a lot of plans probably about forty percent of the time it which means that you they might ask you to do a tier exception or they might or they might say that i’m not going to pay for that in which case now you’re going back to
The appeal that you should have sent the first time anyway even if they decide to use a discount card for example well now that you have to give them discount card and at some pharmacies where it’s more expensive such as walgreens those discount cards might only might still take it down to forty dollars in which case you’re not really saving them that much money
You’re talking to the patient multiple times you probably made three or four phone calls by this amount of time that’s way more expensive than doing an appeal and appeals you know a five-minute phone call that’s what it costs all right that’s that’s that’s the approximate cost so assuming that that has been sorted out they did get it cash then you need to get that
Claims data because if you go and do another prior auth they’re going to say well you said they took zedia but i don’t see any claims data a lot of them will do that so now you need to get the claims data from the pharmacy and if you’re using a cvs or a publix or a walmart shouldn’t be a problem but again some pharmacies such as walgreens for example and you’ll
Know this if you’ve worked with us for a long time they won’t give you that information so now you got to call a patient and tell them to tell walgreens to give them the information or tell them that it’s okay for them to fax the information to us now we have all this information now we can submit this pa again and hopefully get it overturned on pa but of course
If there’s any problem along that process then we’ve got to do another appeal which is what we were going to do anyway and of course in the middle of that process once they’ve taken acetamide they might need to get another lab showing that their ldl is still too low still too high with the zenon so you can see the amount of time that could be spent pursuing that
Process where if you just send the appeal and make the right argument it’s going to be over turned 99 of the time anyway so that’s why the recommendation for this would be to appeal and to only take is that to only do the ezetimide if it takes too long and it’s not really going to make much of a difference for you or if it’s conceivable that it could get them to
Go before i go here i want to give you one more example of how a very small subtlety can change what makes most administrative sense and can save you an insane amount of money for example if we have the exact same denial reasons on the exact same case the ldl and the azitamod if it was not for one more reason which was probably when it completely changes what
Makes the most sense to do if it’s also denied for prevalent what you want to do is nothing what we recommended you don’t want to send for another lab you don’t want to send as that in mind you don’t want to do any of those things you don’t want to appeal it either what you want to do is send for patient assistance and the reason for that is is if you change to
Praluent you still need to get the lab you still may possibly need to try as a zettamine and you’ll still have the same problems are you going to spend all this time dealing with the lab explaining to the patient about the change in drug dealing with the pharmacy with the zettamide and then you need to do another pa possibly another appeal and of course even after
That it may not be affordable to them so you may need to file for patient assistance anyway through a different company right and or file for a grant or copay assistance and then many times especially on medicaid plans for example i know at least in our state the initial approval is only for three months which means you need to do another pa and you need to get
Another ldl lab showing that there’s a reduction and then you have to deal possibly with a specialty pharmacy and then you’ve got to send it over there whereas if you had just sent it to patient assistance then you wouldn’t need to do any of that you simply send it to patient assistance you don’t need to worry about pas you don’t need to worry about the lab you
Don’t need to worry about sending scripts to pharmacies you don’t need to worry about the cost and the reason you can do that is because that patient assistance program at least while i’m making this video currently it can’t change at any time that patient assistance program if the reason it’s denied is due to trial and failure of their competitor’s product they’ll
Let you in for that reason so by simply applying to patient assistance you probably s saved about 80 to 90 dollars of just calling labs getting labs processing labs talking to patients talking to pharmacies talking to insurance dealing with appeals dealing with high co-pays redoing prior rots getting new labs you saved so much money by doing that so a very small
Subtlety can change massively how much administrative burden you are spending at your practice and that’s basically what we do for you you don’t need to know all of this stuff you simply send the request to us and we’ll find the most administratively effective way of dealing with it for your practice given your specific parameters thank you for joining me again
If you have any questions feel free to give us a call send us an email or just add a comment here on youtube and i’ll be happy to get back to you thank you for watching and i’ll see you around
Transcribed from video
Repatha Denial Analysis By CloudTop HealthliveBroadcastDetails{isLiveNowfalsestartTimestamp2021-11-09T153455+0000endTimestamp2021-11-09T154940+0000}