I am apologizing ahead of time to my non-US readers for the confusion you will probably feel after reading this entry. Our health insurance situation in the States is screwy a lot of the time.
Working in a community pharmacy in the US means having to deal with insurance companies about 1/3 of the day. This is true of both techs and pharmacists. We both need to know how to handle phone calls about rejected claims. My story for today is about how tiresome it can be.
I received a call from a woman in the early afternoon asking me if I remembered her situation. After talking to her, I realized I did, in fact, recall dealing with her last month. Her story was complicated, so I was glad I was able to recall the details. This woman’s insurance provider changed their plan details at the beginning of June. Same company, same representatives, but a different plan. This isn’t exactly unusual here in the States. Patients will have everything on their ends stay the same, but things on the insurance carriers’ ends change dramatically. For this woman, this not only meant that she was forced to only come to our pharmacy for prescriptions, but that the amount of pills she could get when first transferring would be different as well. She had always been allowed to get a 90 day supply of her maintenance medications before June. Now, the regulations state any time she gets a new medication that she’s never had before, she must pay her full copay for a 30 day supply first and then in subsequent refills, she can get 90 days’ worth. This wouldn’t be that bad, except that every time she goes to get her pre-existing prescriptions filled for the first time since June, they view it as the first time she’s ever had it ever filled and denies a 90 day supply. It always leads to both the pharmacy and the patient having to call and argue with the insurance provider.
Well, she called and told me she had two other prescriptions that were due to be filled. I told her I would handle the situation like last time, and she thanked me. The prescriptions were put through and (no surprise) they rejected a 90 day supply. I called and got a hold of a representative with a god complex, who told me that this override didn’t exist and that it had never been done in the past. I argued with her, trying to get her to see that it had been done last month with other medications. She basically told me it was a fluke and refused to provide any assistance. I had to call the patient, who then called the insurance provider herself. She returned my phone call a bit later and gave me a specific number to call. I called this number and was transferred to three different departments before someone was finally able to help with the situation. The actual override took about 30 seconds and consisted of a couple keystrokes and computer mouse clicks. The total time I spent dealing with this problem (which really shouldn’t be a problem) was about 45-50 minutes. I was so backed up afterwards that I had to stay an extra half hour after closing to finish checking the rest of the filled prescriptions for the day.
These kind of things are so beyond confusing and take up so much time that should be spent doing ACTUAL pharmacist duties. Because of some error in that insurance provider’s system, not only was time taken away from me, but it caused so much unnecessary stress on the patient. She shouldn’t have to call them in order to get them to listen. That middle man step should not be necessary. But, this is always the case with her medications. I’ll be happy when everything is finally all transferred over from her old pharmacy once and for all. The worst part is that her situation isn’t the most unusual thing I see. There’s a set of quadruplets that when they need medications always require a phone call to the insurance company because they are unable to provide them with their own identification numbers, so any activity appears fraudulent to the provider at first glance. Why they can’t have their own ID numbers is beyond me, but all I know is it causes four children to wait an hour and a half or longer for antibiotics when they all get sick when it should take no more than fifteen minutes.
All I can say to really sum everything up is this: I wish my pharmacy would institute a call center like they’ve been talking about for years now. It would cut down on a lot of this unnecessary stuff and allow more time for patient contact. It would allow more time for me and every other US community pharmacy to actually practice pharmacy.