Health Insurance…My Other Specialty?

 

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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.

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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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Transfers

 

Today, I dealt with several transfers from other pharmacies. There were more than most days, and the common factor seemed to be confusion as to why it would take longer than 15 minutes to fill their prescriptions. Try as I may to explain why, there were just some people who didn’t understand and, therefore, were annoyed and irritated. So, here’s a step-by-step list of what has to happen in order to transfer refills from one pharmacy to another. This list does not include transferring within a chain (ex. transferring a prescription from one Walgreens to another). That process is less cumbersome.

For ease of explaining, Pharmacy A will be the pharmacy you last had the script filled at, and Pharmacy B will be the pharmacy you want the prescription to be filled at now.


Step 1

The pharmacist on duty at Pharmacy B must gather as much information about the prescription(s) you need as they can. When people have their bottle(s) from Pharmacy A with them, it’s a blessing. The more information the pharmacist has before continuing past this step, the faster the transfer will be made.


Step 2

The pharmacist at Pharmacy A must be called by the pharmacist at Pharmacy B. This can only be done by pharmacists and, in some places, pharmacy interns (those studying to be pharmacists).  Therefore, both the pharmacists at Pharmacy A and B must be available for a few minutes per prescription. Depending on the workflow at either store, it can take a bit before the pharmacist from Pharmacy B can make the call and the pharmacist from Pharmacy A can answer the call. I once sat on hold with a mail order pharmacy for 20 minutes before I got a hold of someone.


Step 3

The following information must be documented on prescription pads by the pharmacist at Pharmacy B:

  • drug name
  • drug strength
  • medication quantity
  • directions
  • number of refills remaining
  • prescription number from Pharmacy A
  • date the prescription was written by the prescriber
  • date the prescription was first filled
  • date the prescription was most recently filled
  • the prescriber’s name and credentials
  • Pharmacy A’s address and other information
  • the name of the pharmacist at Pharmacy A

The pharmacist at Pharmacy B must then share his/her name and Pharmacy B’s information with Pharmacy A.  Pharmacy A must document this in their system before continuing. This must be done individually foreach prescription that is transferred. This is why it takes a few minutes per prescription.


Step 4

Pharmacy A inactivates the prescription(s) in their computer, and Pharmacy B fills the prescription(s). That’s where the regular filling process kicks in. See the steps in my entry entitled “Narcs” to see what that entails.

 
Some important things to know about transfers:

  • Narcotic prescriptions cannot be transferred.
  • Some places do not allow for controlled medications of any kind to be transferred, even if they have refills.
  • Prescriptions can only be transferred if the prescription has refills and is not expired.
  • If you are transferring from a mail order service to a retail pharmacy, you may not be able to get the same amount of medication in the store as you do through the mail. A lot of insurance companies (in the US) allow for 90 days’ worth by mail but only 30 days in the pharmacy.
  • The prescription cannot be transferred if the pharmacy it was originally from is closed.

So, that’s my spiel for today. Hopefully, this entry wasn’t too confusing. Hope your days are all going great! =)

 

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