Dealing with the insurance problems the New Year brings

[crossurfingers]

It has been absolute hell for me the last couple of days. All the insurance problems coupled with the already decreased staff hours.

Question- do you take it upon yourself to resolve all these "Non-matched recipient" rejects by calling the insurances to have them look for active coverage? Or do you divert those to the patients and have them call their insurance to sort that out? This problem seems to be a big time waster for me these days.

Also, how do you deal with those that want you to front them a couple of pills for free until they get their insurance straightened out? I've talked to a couple of pharmacists and they have all told me that we shouldn't do this and there is nothing left but have them pay out of pocket. Try telling this to customers though, who let us know that we "always" give them a couple until things get straightened out. They don't seem to understand the difference between giving out an emergency supply pending doctor authorization for refills and an insurance issue.

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[Storm90]

It's the patient's responsibility to update their insurance. You aren't responsible, and you probably have better things to do than sit on hold for 3 hours of your day. As far as loaning pills, it's up to the pharmacist in charge. I had one who would loan 3 days worth of meds for hypertension or epilepsy, but not narcotics or birth control, although some say "I need them!"

 

[The Fargoan]

At my independent pharmacy we call on every single insurance issue while the patient waits. We then take the abuse as they complain about the generic (or "genetic" as it was called today) copay rising from $4 to $7. It is annoying, but the service is what separates us from everyone else. I can't wait for February. . .

My main complaint is the large number of patients that apparently have no clue what their plan entails. . ."It didn't cost that much last year!?!? No they didn't send me anything about costs going up!!"

 

[MadDash]

No way, there are wayyy to many insurance rejects to call them all. I ask if they have a new card. If they say no, I say "Your insurance is saying you no longer have coverage. I can hold these medications for a few days until you get it straightened out, or you can pay cash and get reimbursed later." As far as an emergency supply, I just ask the pharmacist if they would be willing to dispense an emergency supply. It's completely up to them.

We had a guy in today that I heard swearing all the way across the pharmacy because his insurance wouldn't cover something, after the tech spent 15 minutes on the phone with them. The pharmacist went on over and laid down the law. Funny thing was, 20 minutes later we get a call from another store in our chain saying that this guy was now at their pharmacy requesting the medication. Did he think we wouldn't notice and somehow his insurance would magically be OK at the other location???

 

[Farmercyst]

We just ask them for the updated info, if they don't have it, it's usually just too bad, though if it's Part D those can be looked up electronically rather quickly so I'll reTROOP them and sometimes come up lucky. Had one just today that I had to do that with.

 

[Megas]

What I do depends on the person. If the are competent, or rude, I'll ask them to find out their own freaking information. If they are not competent, deaf, confused, etc. I'll do it. Medco was hell to call over the holiday weekend, Ikept getting people who sounded like they were from a place verrry far away who didn't know how to do anything, but I think they have full regular staffing again this week. Just call the insurance, put the muzak on speakerphone and continue your QA, counselling, answering all those crazy questions people have when they decide to ingest all new herbal crap for the new year, etc. until you reach a person.
Farmercyst is brilliant, Part D is easier to get answers out of.
We will charge cash for an ER fill for an expensive drug, no charge ER fills for cheap things (cash for n=3 simvastatin 5 mg? c'mon...).
Yes, it is hell, it is frustrating, it's crazy, it's fantastic! Balls to you!

 

[MountainPharmD]

At my pharmacy I decided this year we are not going to call on insurance rejects. We tell the customer their information has changed and they need to call and get the new info and bring it to us. This has led to many interesting comments. Here are a few of my favorites:

1) I have been trading here for upteen billion years and have never had a problem. (I hear this at least once or twice a week in respone to anything from you might have a deductable to the price went up.)

2.) YOU people always handle my insurance.

3.) Doesn't the insurance automatically send you the new information.

4.) Why do I have to call its not my responsibility.

5.) New card??!?! I have never ever had a card. Can you give me one?

6.) A deductable?!?!?! Gasp!!!I have never heard of such a thing. You need to call and find out what is going on.

7.) It was X dollars in December why is it differet this month? (see deductable comment above.)

8.) I guess I will just have to take my business to Wal-Mart!

9.) I have had the same insurance for 100 years and it has never ever changed!

10.) I could go on but I will stop.

 

[Aznfarmerboi]

For a store who does 600 scripts on a Monday, the first business day of the new year, after a weekend, who has time to call the insurance? I already spend a good 2-3 minutes per patient explaining deductibles much less than higher copays.

Even for slower stores who does 200 scripts, it can still be quite a problem as you can almost expect longer wait times (about 5-10 minutes more) from the insurance themselves.

It is the patient's responsibility to make sure their insurance coverage is updated. The only time I call the insurance company is when it is for a patient who has tried several times and cannot understand what their response was. (Usually due to language barriers rather than ignorance or denial that they got to pay more).

 

[meister]

I'm certainly glad I'm not working in a pharmacy this January. This time of year was always pretty fun. Back in the day I would call on most insurance problems and was willing to spend 5 minutes trying to resolve the problem while the patient stood there. If it was going to take more than 5 minutes or if it's an eligibility issue that is not easily fixable like a SSN search for Medicare Part D I would tell them to call their health insurance and figure out who the **** their pharmacy coverage is administered by. I always found that if you at least attempt to solve the problem then they are far more willing to do work themselves if you can't really figure out the issue.

Since Medicare Part D came into play, however, I found this approach becoming less and less tenable. There are just too many insurance companies, too many formularies, too many rejections, and too many prescriptions to be able to devote 5 minutes to every rejection. What we did was employ a triage system. Anything that was a medically necessary drug such as for AIDS or immunosuppression we would do all we could for the patient. Anything that wasn't really necessary we would tell the patient to figure it out themselves if there was no easy ER M0 1G type fix (you should know what I'm talking about).

Sucks for patients who have a ton of crap to deal with in their lives I'm sure, but what else can you do?

Oh and by the way, Medco was awesome because you could put an override in the computer for vacation supplies and it'll adjudicate online as well as for a lot of drug interactions. Most other administrators, such as BC/Anthem or Blue Shield, are nowhere near as nice.

 

[pharmdinfl]

I am so thankful that now that I work at the VA - I no longer have to hear about insurance problems! We have "people for that".

In my opinion, however, it is the patient's responsibility to keep tabs on their insurance....especially if it's something so simple as finding out their own member ID number!!

I will also never understand how people can sign themselves up for a plan and have no idea of the TERMS and CONDITIONS of the plan. Seriously? That is ridiculous!

 

[crossurfingers]

At my pharmacy I decided this year we are not going to call on insurance rejects. We tell the customer their information has changed and they need to call and get the new info and bring it to us. This has led to many interesting comments. Here are a few of my favorites:

1) I have been trading here for upteen billion years and have never had a problem. (I hear this at least once or twice a week in respone to anything from you might have a deductable to the price went up.)

2.) YOU people always handle my insurance.

3.) Doesn't the insurance automatically send you the new information.

4.) Why do I have to call its not my responsibility.

5.) New card??!?! I have never ever had a card. Can you give me one?

6.) A deductable?!?!?! Gasp!!!I have never heard of such a thing. You need to call and find out what is going on.

7.) It was X dollars in December why is it differet this month? (see deductable comment above.)

8.) I guess I will just have to take my business to Wal-Mart!

9.) I have had the same insurance for 100 years and it has never ever changed!

10.) I could go on but I will stop.

I've heard the same things these past couple of weeks. Did you find that this strategy was more efficient and saved a lot of time? Or was it more of a headache when the customers get bitchy about not wanting to do anything for themselves and causing a scene?

Also, if you have any good tips in how to handle these "comments" they would be greatly appreciated. I usually tell them that we can call but it will take a much longer time than if they called themselves since we're so backed up with calling on other people's stuff and insurances are putting everyone on hold for 5-10 minutes at a time. Sometimes that works, sometimes it doesn't.

 

[DrugDealer]

I've done several transfers this week from other pharmacies, and the patients keep complaining that CVS charges more than their old pharmacy.

Patient: "Why do you charge more here?"
Me: "We don't charge you, your insurance does, and it works the same everywhere."
Patient: "But I always pay $5 at XXXXX pharmacy."
Me: "But that was in 2008. I doubt you've been there in 2009."
Patient: "But I always pay $5 at XXXXX pharmacy."
Me: "Your plan changed with the new year. You will now pay $20 at XXXXX pharmacy."
Patient: "But I always pay $5 at XXXXX pharmacy."
Me: "Well, it's a new year everywhere, not just here at CVS. It's also 2009 at your other pharmacy."
Patient: "But I always pay $5 at XXXXX pharmacy."
Me: "Would you like to take your prescription to XXXXX pharmacy and see how much "they" charge you today?"

 

[Lurkerkat]

The main issue I've had is people not understanding the concept of a deductible. A lot of people don't seem to understand that it resets every year ("But I paid the deductible last year!") and then they try to come up with some crazy scheme to get around it. One person wanted me to dispense only 15 days worth of meds, another wanted to try mail order, another was going to take it to another pharmacy. Lather, rinse and repeat with me explaining that no matter how you get your medications (quantity, pharmacy, mail-order), you're going to have to pay $200 out of pocket before you get drug coverage.

 

[meister]

The worst part is that you can't really blame the patients for not really understanding their insurance because the entire system is designed to obfuscate and screw them over. It really is pretty goddamn sad.

 

[WVUPharm2007]

The main issue I've had is people not understanding the concept of a deductible. A lot of people don't seem to understand that it resets every year ("But I paid the deductible last year!") and then they try to come up with some crazy scheme to get around it. One person wanted me to dispense only 15 days worth of meds, another wanted to try mail order, another was going to take it to another pharmacy. Lather, rinse and repeat with me explaining that no matter how you get your medications (quantity, pharmacy, mail-order), you're going to have to pay $200 out of pocket before you get drug coverage.

One really good idea we had a customer do is to have a dummy script for an expensive medication...make a pharmacy run it through...then never pick it up. As far as the third party knows, the deductible is gone...and you pay normal copay. We figured this out after this dude kept getting scripts for Byetta filled once a month, then we'd credit it...and he'd come back...we'd fill it...it'd sit there...and cycle over and over...we didn't notice until about 5 months in because he wasn't a regular or anything. All the while he was getting his real meds down the street at another pharmacy without ever paying his deductible. Quite a brilliant little scheme, actually...

 

[MountainPharmD]

One really good idea we had a customer do is to have a dummy script for an expensive medication...make a pharmacy run it through...then never pick it up. As far as the third party knows, the deductible is gone...and you pay normal copay. We figured this out after this dude kept getting scripts for Byetta filled once a month, then we'd credit it...and he'd come back...we'd fill it...it'd sit there...and cycle over and over...we didn't notice until about 5 months in because he wasn't a regular or anything. All the while he was getting his real meds down the street at another pharmacy without ever paying his deductible. Quite a brilliant little scheme, actually...

Damn thats a good one! I will have to watch out for that one.

 

[meister]

Alert his insurance provider as that is fraud. It is idiots like him that add to our ****ty problems. I'd love to see the look on his face when he gets a bill for $2000 to make up for the deductible he didn't pay.

 

[pharmwannebe2]

At my pharmacy I decided this year we are not going to call on insurance rejects. We tell the customer their information has changed and they need to call and get the new info and bring it to us. This has led to many interesting comments. Here are a few of my favorites:

1) I have been trading here for upteen billion years and have never had a problem. (I hear this at least once or twice a week in respone to anything from you might have a deductable to the price went up.)

2.) YOU people always handle my insurance.

3.) Doesn't the insurance automatically send you the new information.

4.) Why do I have to call its not my responsibility.

5.) New card??!?! I have never ever had a card. Can you give me one?

6.) A deductable?!?!?! Gasp!!!I have never heard of such a thing. You need to call and find out what is going on.

7.) It was X dollars in December why is it differet this month? (see deductable comment above.)

8.) I guess I will just have to take my business to Wal-Mart!

9.) I have had the same insurance for 100 years and it has never ever changed!

10.) I could go on but I will stop.

haaaaaaaa walmart doesn't want your business! we have enough insurance problems. it is hell.

everyone yesturday had a new card and didn't get it in the mail yet.

 

[Lurkerkat]

One really good idea we had a customer do is to have a dummy script for an expensive medication...make a pharmacy run it through...then never pick it up. As far as the third party knows, the deductible is gone...and you pay normal copay. We figured this out after this dude kept getting scripts for Byetta filled once a month, then we'd credit it...and he'd come back...we'd fill it...it'd sit there...and cycle over and over...we didn't notice until about 5 months in because he wasn't a regular or anything. All the while he was getting his real meds down the street at another pharmacy without ever paying his deductible. Quite a brilliant little scheme, actually...

Probably wouldn't work with our system since I work at Kaiser. I'm not certain if they take their script to an outside pharmacy if they can get that to apply towards their deductible. If it did they'd probably want to see some receipts as evidence of the transaction. Although that explains why one of my patients kept insisting they'd take it to an outside pharmacy and it'd all work out.

 

[WVUPharm2007]

Alert his insurance provider as that is fraud. It is idiots like him that add to our ****ty problems. I'd love to see the look on his face when he gets a bill for $2000 to make up for the deductible he didn't pay.

Dude...that was like three years ago...and he did get caught...though from what I understand, they just froze all payments until he paid for his deductible...

 

[clachan3]

Love it when we have to ask them, "Do you have a new insurance card *FOR 2009*??" You know, it is a new year....and oh we got 34 scripts rejected in the queue because Anthem was down on Jan 2nd