Is it permissable to run "test claims" in retail pharmacy?

[justjoe]

Sometimes patients will call and ask us what a medication costs though their insurance. However, they don't have a prescription on file. Is it permissible to run a fake rx through to see what their copay is, then reverse it?

I've had another pharmacist say that the insurance companies don't like it when we do test claims with out an actual prescription on file.

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[Lnsean]

No. Tell the patient to bring scripts or call the insurance themselves. You're opening yourself up to a lot of bs and unnecessary work.

 

[WVUPharm2007]

At CVS, there is a "formulary check" option that just runs a test claim with no further deleting or paper chucking necessary.

Is it possible...does CVS have a useful feature other companies don't?

 

[hye345]

At CVS, there is a "formulary check" option that just runs a test claim with no further deleting or paper chucking necessary.

Is it possible...does CVS have a useful feature other companies don't?

I've used this feature, but very rarely is it actually useful... Nine times out of ten, the test claim fails, and (by design) it never gives any reason as to why.

 

[WVUPharm2007]

I've used this feature, but very rarely is it actually useful... Nine times out of ten, the test claim fails, and (by design) it never gives any reason as to why.

...usually works for me.

 

[mentos]

At CVS, there is a "formulary check" option that just runs a test claim with no further deleting or paper chucking necessary.

Is it possible...does CVS have a useful feature other companies don't?

How do you do this? Never knew about it.

 

[Rukn]

We sometimes just scan a blank Rx paper and use that, depending on how annoying the customer is

 

[maria1oh]

It is illegal to run test claims on medicare part b but I don't know about other ones. I have done this myself before and delete the claim out right away. Prescribers have also called before asking if something is covered. Formulary check option did not seem to always work for me at cvs. Just like cvs had a way to look up someone's insurance but it did not always work. Maybe it depends on their insurance company whether the eligibility check and formulary check will work correctly.

If you tell patient to call insurance to find out price the insurance will likely tell them how much cheaper it is via mail order.

 

[fauxden]

i do it all the time

 

[Rouelle]

How do you do this? Never knew about it.

Instead of typing in a new script from their profile, hit the F key

 

[mentos]

Someone told me that if you run a claim then reverse it, the pharmacy doesn't get fully reimbursed. They end up paying a small percentage fee. That's probably why it's not allowed.

 

[BenJammin]

Sometimes patients will call and ask us what a medication costs though their insurance. However, they don't have a prescription on file. Is it permissible to run a fake rx through to see what their copay is, then reverse it?

I've had another pharmacist say that the insurance companies don't like it when we do test claims with out an actual prescription on file.

Do you really have time to run test claims?

 

[Sine Cura]

There may be a nominal cost associated with just submitting a claim and the CVS formulary check will fail if there is a refill too soon conflict or some other DUR conflict IIRC

 

[ChalupaBatman86]

You pay a few cents every time you submit a claim.


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[Dr Wario]

Do you run "test claims" on peoples' credit cards? I don't have time for that, people are welcome to call their insurance companies.

 

[Rukn]

You pay a few cents every time you submit a claim.


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All the more reason to do it

 

[TheBlaah]

I've only done test claims if a doctor was on the line trying to prescribe something that was covered.

I wouldn't do it for patients who are just calling in without a prescription though.

 

[owlegrad]

Do you really have time to run test claims?

Takes about the same amount of time to run a formulary check as it does to tell someone you won't do it. Or at least that was my experience at CVS. Plus the patient is happy rather than upset. The only advantage I can see to refusing to do it is that warm feeling you get from refusing to help people.

 

[radio frequency]

Takes about the same amount of time to run a formulary check as it does to tell someone you won't do it. Or at least that was my experience at CVS. Plus the patient is happy rather than upset. The only advantage I can see to refusing to do it is that warm feeling you get from refusing to help people.

Not everyone works at CVS. I've never worked anywhere where I could run a formulary check. That would be an awesome upgrade.

 

[owlegrad]

Not everyone works at CVS. I've never worked anywhere where I could run a formulary check. That would be an awesome upgrade.

That's true, but the person I was responding to said he didn't have time, not that he didn't have the capacity.

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[DRHRT]

YES, cvs does have a formulary check feature. & i've seen sooooooo mannnyyyyy pharmacists ( & techs) do it. as long as u reverse it, it shouldnt be a problem

 

[Lnsean]

People, you are barely staffed as it is to fill REAL prescriptions...stop wasting your time and resources typing up FAKE scripts and running FAKE claims. You should not be running fake claims. Tell the pt to call their insurances. Don't make this a habit. Every time I tell a patient I cannot knowingly submit fake claims just to find out their copays and they reply "..but XYZ pharmacy does it for me all the time," I want to walk over to XYZ Pharmacy and punch the staff in the face for setting this kind of behavior.

 

[Leper Messiah]

I'm genuinely surprised that "formulary checks" don't exist on most computer systems. Definitely don't run a fake claim, especially with Medicare. It's costing you money in the best case and it's fraud in the worst case.

 

[trailerpark]

If another pharmacy does it than tell people to go do it there.


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[txpharmguy]

I do it often on rxs that require prior authorization and plan doesn't give alternatives. I figure out what's covered and send fax saying drug X requires prior authorization, but drug Y is covered. More often than not, I get an rx for my "recommendation." I rarely do this for patients unless I know them pretty well.

 

[6GodPharm]

Some of you guys do the dumbest things and then b*tch about retail. Half this crap we bring on ourselves. Just let them know we have to have the RX to run it through the insurance. I've even have had patients try give me the insurance info over the phone, well sorry mrs smith, you need to bring that ass to drop off because I have a dr line and a counsel waiting for me. Find ways to make your life easier guys.

Also this formulary check for CVs is not accurate. 90% of the time it rejects but if you run it as you have the rx it goes thru. Don't trust it.

 

[VA77]

This type of stuff is what auditors love. Insurance company says they didn't get a reversal and it will take months to get your money back on a $4000 Enbrel Rx. Your manager is going to love you plus those pennies add up over a period of time.

 

[owlegrad]

YES, cvs does have a formulary check feature. & i've seen sooooooo mannnyyyyy pharmacists ( & techs) do it. as long as u reverse it, it shouldnt be a problem

There is nothing to reverse if you do the formulary check option, just FYI.

 

[owlegrad]

Some of you guys do the dumbest things and then b*tch about retail. Half this crap we bring on ourselves. Just let them know we have to have the RX to run it through the insurance. I've even have had patients try give me the insurance info over the phone, well sorry mrs smith, you need to bring that ass to drop off because I have a dr line and a counsel waiting for me. Find ways to make your life easier guys.

Also this formulary check for CVs is not accurate. 90% of the time it rejects but if you run it as you have the rx it goes thru. Don't trust it.

Right, because making someone bring in their card and wait for it to be inputted and then wait for their script to be reran through the insurance is soooo much more efficient than just entering the info over the phone and having the script ready to be picked up when the patient arrives. Genius! Thank you for this insight, if only I had thought of this when I worked at CVS, I probably would have loved my job!

 

[6GodPharm]

Right, because making someone bring in their card and wait for it to be inputted and then wait for their script to be reran through the insurance is soooo much more efficient than just entering the info over the phone and having the script ready to be picked up when the patient arrives. Genius! Thank you for this insight, if only I had thought of this when I worked at CVS, I probably would have loved my job!

When your store does 3300/week with just 2 pharmacists because of shortages yes. You do whatever necessary to make a efficient Pharmacy. I don't need my techs to spend 5-10 minutes over the phone trying to get a customer to find where the Bin # is and then getting wrong info inputted. Just bring the damn card in. Same thing for rebills in the drive thru. I've seen stores where they do insurance and rebill thru the drive thru. After the transaction is done you have a line of 6-7 cars in drive. MCE goes straight to hell. You have 1 happy customer (because you did everthing thru drive thru) and 6 pissed off ones behind them. It's simple, get people in and out. Our MCE is 12 points over target just on. The extra BS we try to do we put on ourselves. Maybe you know that now that you're no longer around?

 

[owlegrad]

Drive thru is a nightmare I do not miss at all. Although I am not totally sure I understand what you are trying to say about not doing insurance through the drive through (I assume you mean you make them come inside?), I do agree that letting someone sit in drive thru while the line backs up to several cars deep is just bad for business. I used to just type in their insurance information and have them drive around while we reprocessed the script. Keeps the line moving and keeps people from bitching about how inconvenient it is to -gasp- come inside the store. *eyeroll*

Also why not just use the insurance look up feature? I know it doesn't always work but man that was one of the few updates I actually loved. Being able to process a script using the insurance without the need to have someone standing around waiting for it to be reprocessed was just the best. And talk about efficient, nothing is more efficient than having a script ready to be picked up rather than trouble-shooted.

 

[Abby Atwood]

I wouldn't run a test claim; but, if a patient seems less than capable of getting the information for themselves, I will give the insurance company a call on their behalf. I'm an intern though. I don't know if a pharmacist would be able to set aside that kind of time. It usually takes 5-15 minutes.

Starting to wish I worked at CVS

 

[dblock05]

i run them occasionally for my patients instead of doing the formulary check. Its really not a big deal. Just delete it right away afterwards.

 

[TheWisePharmacist]

THE BEST ANSWER

"Call the number on the back of your insurance card and give them the information on the RX and tell them you want to get it at (your pharmacy name here). They can tell you which pharmacy it will be the cheapest at as well as if you need a prior authorization"
-Walgreens Pharmacist

This is the standard procedure of all pharmacies I go to. Why is it the best answer?
1. Saves your time
2. Can answer quickly any question regarding payment for the patient or healthcare provider.

If a doctor, nurse, or receptionist calls I'll give them the phone number of the patients insurance. If I'm not busy I may do a test run for them, but its rare.

 

[whitwhit]

I would kindly direct them to the back of their insurance card, and tell them to hit that claims center up. They waiting.

 

[Lnsean]

Some of you guys do the dumbest things and then b*tch about retail. Half this crap we bring on ourselves. Just let them know we have to have the RX to run it through the insurance. I've even have had patients try give me the insurance info over the phone, well sorry mrs smith, you need to bring that ass to drop off because I have a dr line and a counsel waiting for me. Find ways to make your life easier guys.

Also this formulary check for CVs is not accurate. 90% of the time it rejects but if you run it as you have the rx it goes thru. Don't trust it.

For real...people don't even have time to do real work...some of you guys looking for fake work to do.

 

[MV777]

Sometimes patients will call and ask us what a medication costs though their insurance. However, they don't have a prescription on file. Is it permissible to run a fake rx through to see what their copay is, then reverse it?

I've had another pharmacist say that the insurance companies don't like it when we do test claims with out an actual prescription on file.

I will run a fake script through and immediately delete it after to let them know the cost. Of course, this depends on the drug they are asking for and how busy we are. I'm not quite sure if it's "permissible" or not but it's really the same as running a real script through then handing a prescription back to a patient if it's too expensive and they ask for it back I would think

 

[Apotheker2015]

THE BEST ANSWER

"Call the number on the back of your insurance card and give them the information on the RX and tell them you want to get it at (your pharmacy name here). They can tell you which pharmacy it will be the cheapest at as well as if you need a prior authorization"
-Walgreens Pharmacist

This is the standard procedure of all pharmacies I go to. Why is it the best answer?
1. Saves your time
2. Can answer quickly any question regarding payment for the patient or healthcare provider.

If a doctor, nurse, or receptionist calls I'll give them the phone number of the patients insurance. If I'm not busy I may do a test run for them, but its rare.

Exactly! Patients can call their insurance company to get their copay. Better yet, they can download the app for whatever insurance they have, accesss their formulary and get copays.

Sharing those steps with patients is not poor customer service or refusing care. Every time I see a doctor I bring the app, access the formulary and tell them what my plan covers.

I see clinics sending us faxes all the time asking "what's covered?". We tell them to call the patient's insurance.

If you have the option at CVS of using "formulary check", awesome - if you have time. "Formulary check" was probably created to avoid running fake claims in order to find out patients' copays. Well, the feature was not necessary to begin with. Pharmacists and technicians should have been telling patients to call their insurance or access their formulary and plan via the interwebs.

 

[bryan6977]

check out website pharmacybenefits site.

they have tools and apps to do all this.

 

[CetiAlphaFive]

check out website pharmacybenefits site.

they have tools and apps to do all this.

Thanks "Bryan"

 

[Sabril]

Sometimes patients will call and ask us what a medication costs though their insurance. However, they don't have a prescription on file. Is it permissible to run a fake rx through to see what their copay is, then reverse it?

I've had another pharmacist say that the insurance companies don't like it when we do test claims with out an actual prescription on file.

The lady that came to audit us from OptumRx told me we were not supposed to do test claims. So that's that.

I still do it from time to time to serenade doctors and patients. I guess I'm getting punched.

But in my experience, most people who asked that question were just shopping around and already got those scripts filled at another pharmacy. They were just aghast with their copay. So I just tell them, one- I cannot run a test claim if the other pharmacy has not reversed it, and two-their copay will most likely be the same.

If they are really obnoxious, I will even tell them to try their mail order pharmacy.