Health Insurance…My Other Specialty?



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.


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So, I feel all better! Hooray! I worked yesterday, but it was a repeat of Saturday, so I didn’t even bother posting. Today was like a whole new world, though, and food has never tasted better. =) So, back to the normal entries!

I feel the picture up above is a great description of many types of drug regimens. You start at one point, and you may continue along that line for the entire time you’re on it. But, at any given time, the prescriber may decide the dosage should be changed or something should be added/subtracted. This can leave patients confused about what to take and when. This, in turn, leads to all kinds of issues.

Lately, I’ve been coming across a lot of the same general problem. People come into the pharmacy and want to fill Drug X. We attempt to fill it, and it is WAY too early, so the insurance rejects it. Now, I’m not talking 4 or 5 days early. I mean 14-20 days too early. I tell the patient this, and the most common reply, as of late, has been, “Well, the doctor told me to double it, so I’ve been taking two pills instead of one.” This situation has also applied to diabetes testing supplies a lot lately too. I try to explain that without a new prescription with the new directions, there is nothing I can do to get the insurance to cover it, but people tend to either get upset or confused. So, allow me to lay out the scenario here in short story format, and then I’ll explain where things went awry.

The character below is purely fictional. Any resemblances or similarities are purely coincidental.

Bertha Jones comes to the pharmacy with a prescription for Accu-Touch Lite blood glucose meter and supplies (notice my play on common brand names there ^_~). Her endocrinologist wrote on her prescriptions that she uses her supplies to check her blood sugar twice a day, since she is a newly diagnosed diabetic. Bertha’s insurance covers everything for a 30 day supply, and she gets the meter for free. Bertha is a happy patient and goes home to start using everything that night.

About a week after her first refill, she goes for a follow-up visit with her endocrinologist. Her blood tests and other such things haven’t improved. In fact, they’ve worsened a little bit. The physician wants her to start testing her blood sugar more often. He tells her to test herself 4 times a day until her next appointment. She sighs, but understands the importance and starts following the physician’s orders. Ten days later, she’s down to only two test strips. “Oh no!” she thinks to herself, and she rushes off to the pharmacy. She tells them what she needs refilled and says she wants to wait. She just takes a seat, only to be called back to the drop off window. The person there tells her the insurance won’t pay for the supplies for another week.

“But, I’m almost out!” she tells them. “I only have two strips left!”

The person at the window tells her she just filled them a little over two weeks ago, and that she should have more than enough at home. She insists that she doesn’t because her endocrinologist told her to start using them 4 times a day, instead of 2. She is told that she needs a new prescription stating this or the insurance won’t cover it. “But, why?” she wonders. “My doctor told me I could. Isn’t that enough for the insurance?” She tries to explain herself more to the person, but they keep telling her she needs a new script. She gets frustrated and leaves. “I’ll just have to wait a week, I guess.” She uses her last two test strips and decides to return to the pharmacy once the insurance will pay for it. She never calls her physician, and the pharmacy never receives a new prescription. This pattern repeats itself until she is out of refills and is forced to get a new script.


So, where did things go wrong? Ms. Jones was on track with her first refill. What happened? Well, her physician made a significant change to her testing regimen. He doubled the frequency. The good news is that she understood it and followed his directions. The bad news is that no one else involved in Bertha’s health care knows this. The one and only way both pharmacies and insurance companies know when something has changed is by having a prescription alerting them of the change. Otherwise, both assume all is the same. So, when Bertha ran out of the test strips, she couldn’t get a refill. Why? Because only her and the physician know something has changed. To the pharmacy and the insurance company, it appears that Ms. Jones is only using her supplies twice a day, even though that’s not the case. So, Bertha cannot get her refills based on the original script.

So, then is it Bertha’s fault that the pharmacy was unaware? No, not really. The physician should be well aware that any changes in therapy have to be documented and sent over to the pharmacy. But, some physicians forget or their office staff doesn’t get around to it or things get lost in translation or a bunch of other things arise that may have prevented this. Whatever the reason, though, there are many times that physicians increase the frequencies of therapies and don’t notify the pharmacy. This leads to much frustration on the patient’s part, unfortunately.

So, how can this situation be avoided? It’s simple. Anytime something changes with your prescriptions, whether it be for diabetes supplies, like in the above example, or for other maintenance medications, TELL YOUR PHARMACY. Actually, the best thing to do is to ask the physician before you leave the office for a prescription for the changed prescription. But, even if you don’t, by telling your pharmacy, they can call the physician’s office if it doesn’t show up. Now, in the ideal world of retail pharmacy, this would be done on the day you have your appointment, and the pharmacist will call you to let you know when it has arrived. In the real world of retail pharmacy, this doesn’t happen and never will due to high volume. It’s not that we don’t want to; it’s that we don’t have the time to do this for everyone every single day. So, as a huge favor to your pharmacy staff, try to remember to give us a call the day after your appointment to ask about the new prescription. By then, the physician will have had ample time to send it over, and the pharmacist will be sure to call on it if it’s not there. A really good pharmacist will remember your name and call you back when the prescription has been filled. (*coughcough* ^_^) All self-praising aside, I do try to do this if I personally speak with the patient, since it’s how I would want my own family treated. I don’t typically answer those calls that much (my techs do), and a phone call takes all of a minute.

So, yeah, that’s my blurb for today. Long-winded, I know, but I think I made my point clear. I think. Let me know if it seems choppy or confusing. =) Toodles!


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