Abstract
Prior authorization has been used extensively as one of the mechanisms to control costs and ensure quality of care by the National Health Insurance (NHI) plan in Taiwan. An appeals system, the Dispute Mediation Committee (DMC), independent of the NHI, is available for interested parties to dispute denials of prior authorization. Currently, medications for Alzheimer's disease constitute the largest category of appeals. To describe the appeals system and analyze outcomes of cases of medications for Alzheimer's disease submitted to the Bureau of NHI (BNHI) for prior authorization and to the DMC for appeals. Prescriptions of donepezil and rivastigmine submitted for prior authorization from 2000 through 2002 were analyzed. Cases denied prior authorization and later submitted as appeals to the DMC were summarized with descriptive and bivariate methods. A total of 12,237 cases of donepezil and 6975 cases of rivastigmine were submitted to the BNHI for prior authorization; among them, 72.6% of donepezil and 66.5% of rivastigmine cases received authorization. Among the thousands of cases denied prior authorization, 124 appealed to the DMC for dispute resolution. The result of the majority of the appeals (111 [89.5%]) was to uphold the BN...Continue Reading
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