How can Optima & BCBS wrongfully deny prior auths?

I have worked in multiple medical practices; I have noticed Optima and BCBS wrongfully deny medication prior authorizations the most. Several other insurance companies wrongfully deny pre certifications for services… how do they get away with it? Why is their no one governing the quality of these PA reviews?

1). Optima (worst): Doctor prescribes a medication. Pharm notifies us PA is needed. PA is submitted to insurance, gets denied because “not medically necessary.” They have a list of medications you will need to try before they pay for the med. Samples dont count as a failure (even if you had a reaction. Severity of the rxn does not matter). A med is not considered failed unless Optima pays for it specifically (but they will not acknowledge their own previous claims without the provider specifying the names of failed medications first). Anything OOP or paid for with a copay card will not count as a failure, even if it’s ineffective, even if it caused a reaction, even if a previous insurance company paid for it. I personally have obtained receipts from Pt’s pharmacies showing that a prescription was filled, and that it should count as a failure. (Pt used a copay card for nurtec and had a reaction where she felt dizzy, her migraines worsened, felt very bad – optima denied it bc she needed to be “prescribed nurtec if she wanted it counted as a failure.” The copay card meant that optima didnt pay for it, and if optima didnt pay for it then its considered a sample. wow. ). If you want any discussion on the PA outcome, you have to submit an appeal (with signed consent from the Pt), or have the medical provider do a P2P. This is absolute corruption. How are they not being held to any standards?

2). Carecentrix: they deny services and do not state the reason for denial. They claim to “mail the denial reason” to the medical provider and only fax the notice of denial as a courtesy. Since when can they chose to not disclose the reason for denial? PA is denied and you have to spend 30-60 minutes on the phone to get the reason for denial. Then it has to be appealed. An Example that happens multiple times a week: we receive a PA denial for a sleep study. The sleep study was ordered bc the CPAP supplies PA requires a recent sleep study before it can be approved. Well, the sleep study PA is denied bc the Pt already had a sleepy study that diagnosed OSA. Unless Pt has a severe medical condition or 10% weight gain/loss, the PA is denied. Okay, so how do they get their CPAP supplies..? They just fuck off then?

3). Anthem: anthem… please… just have one person in your call center that knows something. Anything. No one in that call center knows what department does what. Each phone call is painful. I have not met a more useless individual than every time I call anthem’s provider services line. They are not nearly as bad as optima, but they will not review any clinical information submitted if it’s more than 5 pages. The exact information they need to approve the medication can be included on the information submitted, and they will not read the exam notes. (I would love some insight on this… what exactly is happening over there, anthem…?). They will not review appeals unless you submit a signed consent form from the patient, which is hilarious because the medication was prescribed by this office and the PA was submitted by this office, but to review an appeal you need signed consent? We all know it’s so that the process can be delayed further. Absolute shame on you.