Test Claims. Can you do them? Do you do them?

[Old Timer]

Guys in retail:

Does your software allow to do test claims? Do you do them for providers so they an determine in advance which drug in class is covered and what the copay is?

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[WorthlessOxygen]

Not allowed to because most insurances consider it a "misuse of patient information" from the couple audits that I've been involved in. But I'll do them for the provider.

The way I see it, I'm just processing a verbal order in real time and I had know way of knowing that the provider was going to cancel the rx at the end of our conversation.

 

[Old Timer]

Not allowed to because most insurances consider it a "misuse of patient information" from the couple audits that I've been involved in. But I'll do them for the provider.

The way I see it, I'm just processing a verbal order in real time and I had know way of knowing that the provider was going to cancel the rx at the end of our conversation.

I don't see how how it could be a misuse of information if it is at the patient's or prescribers request. It's built into the NDCPDP protocol to be able to send a test claim.

 

[WorthlessOxygen]

I don't see how how it could be a misuse of information if it is at the patient's or prescribers request. It's built into the NDCPDP protocol to be able to send a test claim.

I don't get it but it did come up in both of my recent audits

 

[owlegrad]

From a practical standpoint, how could it possibly come up in an audit? How would they even know? How could they tell the difference between a "test claim" and "mistake" or "the patient changed their mind"?

 

[Sparda29]

Do it all the time to find out what drugs are not covered by a formulary or which NDCs have better reimbursements.

 

[minzi]

No our software doesn't have that test claim option. I was told everytime we run a rx through the insurance, our pharmacy gets charged a small fee to process that rx.

 

[JustFillIt]

I would do this constantly in retail. I would just bill it and reverse it immediately after. If I ever got audited I would just not admit to a “test claim”. I would just say I do not recall the circumstances surrounding the situation and move on.

 

[WorthlessOxygen]

or which NDCs have better reimbursements

I hadn't considered this but now I suspect that may be why test claims aren't allowed.

From a practical standpoint, how could it possibly come up in an audit?

For my audits, I wasn't actually questioned about any claims that were reversed. But it was discussed during their tips to avoid charges at the end of theaudit and was included on their best practices sheet along with their calculations for eye drop day's supply and rules for topicals.

 

[Pronounce Doxazosin]

I think most retail companies’ policy is that you are not allowed to do it because of “potential” for fraud. Not to mention they lose a fraction of a dollar for each claim IIRC.

With that said, I do it all the time for health care professionals. If it’s a patient, then I tell them to call the insurance

 

[Sparda29]

I hadn't considered this but now I suspect that may be why test claims aren't allowed.

Hey, you gotta do it to maximize profit. I've found that there would be a multiple generics of a drug and some would pay much much better than the other ones. Then you know which ones to order and stock.

There are some prescriptions that pay so little that you automatically lose money on just by filling it because the payment is less than the cost of the claim, the orange bottle, the labels, etc. We should be getting at least a $10 fee on regular prescriptions.

 

[CetiAlphaFive]

I didn't even realize this was a question

 

[pharm B]

Not allowed to because most insurances consider it a "misuse of patient information" from the couple audits that I've been involved in. But I'll do them for the provider.

This is part of why I'm getting out. I just got a fax from CVS about "best practices" including this statement. It's irritating and I'm happy to leave it behind.

Just think: someone gets paid to check for and enforce that kind of crap. Probably don't even work until 9 at night or on weekends.

 

[Old Timer]

This is part of why I'm getting out. I just got a fax from CVS about "best practices" including this statement. It's irritating and I'm happy to leave it behind.

Just think: someone gets paid to check for and enforce that kind of crap. Probably don't even work until 9 at night or on weekends.

I think you are confusing making a fake script with what CVS calls a Formulary Check. It's built into RX connect. No farud involved, no chance for error, no chance for fraud as it is not a real claim.

 

[BenJammin]

Pharmacists wonder why PBMs treat them like trash. Anyone really surprised? You guys brag about being pseudo insurance agents instead of making patients have an interest in their own health care plan coverage.

 

[JustFillIt]

Pharmacists wonder why PBMs treat them like trash. Anyone really surprised? You guys brag about being pseudo insurance agents instead of making patients have an interest in their own health care plan coverage.

The environment which has been created, without our consent, does not foster an environment where we can simply say, “the price is due to your insurance, if you have a problem with this call your insurance company.” Unfortunately the public just does not understand that it truly is their responsibility - and if we push even a little the douche bag Adderall addict district manager will call and give us a warning to avoid customer service issues or get fired.

Maybe your circumstance is different at an independent- but overall your recommendation is not practical

 

[owlegrad]

Pharmacists wonder why PBMs treat them like trash. Anyone really surprised? You guys brag about being pseudo insurance agents instead of making patients have an interest in their own health care plan coverage.

A patient asking what their copay will be is them having an interest in their own health care plan coverage though.

 

[CetiAlphaFive]

Pharmacists wonder why PBMs treat them like trash. Anyone really surprised? You guys brag about being pseudo insurance agents instead of making patients have an interest in their own health care plan coverage.

Cringe and poorly thought out reply. Better to let them know what their copay is than to let it progress through the workflow and waste extra time

 

[BenJammin]

Cringe and poorly thought out reply. Better to let them know what their copay is than to let it progress through the workflow and waste extra time

Or they could call the insurance themselves and decide whether or not the copay is worth the trouble. You can call my comment cringe all you want. The PBMs own you. They tell you to jump and you ask how high.

 

[CetiAlphaFive]

What a brave and controversial statement!