Physician Spotlight
Meet Claudia L. Gaefke, MD, Allergist & Immunologist at Allergy Asthma Clinic, Ltd. She shares her thoughts on the impacts of insurance on private practice.
From Print Issue - Fall 2022
Q: Are there any insurance carriers you do or do not accept? Why? Why not?
The practice accepts most commercial insurances and Medicare to serve the pediatric, adult and geriatric community in the Valley.
Q: Do you see insurance carriers as a partner or roadblock to providing care?
Both. Carriers allow patients to search for physicians in the area within their specialty of choice, make reviews available to other patients, and encourage patients to seek preventative care. Nevertheless, carriers can unfortunately also be a roadblock when it comes to physicians’ ability to choose individualized management plans, specifically choice of medication class or brand.
Q: Which treatments are most often denied by insurance carriers? How do you respond?
Specific class or brand of inhaler medications for the management of asthma are the most often denied medications that I have seen. Also, non-steroidal topical regimens for atopic dermatitis, such as Crisaborole, are frequently denied. Biological therapies for uncontrolled chronic idiopathic urticaria, asthma, and atopic dermatitis, can at times be difficult to get approved.
Particularly when it comes to inhalers, given the frequency in the lack of coverage, there is dedicated staff in the practice to handle prior authorization requests. As the physician, I also direct letters to the carrier detailing indication and medical necessity, if needed. Additionally, patients are aware of the roadblocks that they may encounter with an inhaler or inhalers of choice, therefore if denied, they are instructed to request either the pharmacy or insurance carrier to provide me with a list of covered inhalers under their individual plan.
Lastly, samples of biologicals and inhalers are provided by manufacturers to aid with this process.
"A physician's autonomy in practice preference should also be respected."
Q: Is it relatively easy or difficult to join insurance networks?
Physicians at the practice have been able to join insurance networks without difficulty.
Q: Are there improvements you would like to see in the healthcare system regarding how physicians interact with insurance carriers?
Yes. When a physician’s recommendation for a specific treatment needs to be reviewed by a carrier’s representative, a peer-to-peer review within the same specialty would be optimal, to prevent delays in care.
A physician’s autonomy in practice preference should also be respected. In my experience, a carrier can require a physician to obtain a full schedule DEA, for example, even if not a necessity to the specialty or physician’s preference, in order to participate.
Q: Do you offer telehealth visits and get reimbursed at the same rates as in-person?
The practice offers telehealth visits when in person appointments are not feasible for the patient. Reimbursement to the practice has varied in the past years based on insurance carrier and of course during and after the COVID 19 pandemic and its associated evolving coding policies.