So I Have Been Wondering...

[FreshOffTheBoat]

whats a phone conversation like with an insurance company? retail pharmacist does this a lot right? i mean do they do it for almost every prescription?


so yea....whats the convo like? what exactly is said? is there a real person on the other line or some machine? the conversation can't be that long...no time to talk too long right?

tell me about it....

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[Allure]

It wouldn't make any sense if they have to call the insurance company for every prescription. Most of the time, techs do it and you do get to talk to a real person or else you wouldn't be able to solve the problem. Maybe a job at the pharmacy would help you answer those questions.

 

[MountainPharmD]

That is why we have pharmacy technicians. I have never called an insurance company as a Pharmacist......

 

[FreshOffTheBoat]

you guys didnt do this stuff as an intern?


even if you guys dont do it...arent yall suppose to learn about it? just askin...




yea i have applied to pharmacy tech...i'm tryna to learn more about pharmacy...

 

[ttopping]

You usually call if you get a rejection on a prescription you really don't understand. Mostly you call, eventually get someone on the other line, give the insurance person your pharmacy's NPI or NABP number, then the patients card ID number (and name probably), and the problem you're having. Hopefully they can sort it out and then you can do whats needed to get the script through the insurance on the computer. That's really about it

 

[twester]

It's more like one out of 20 scripts, maybe not even that much. Often the software that interfaces with the third party will give enough information that you know why you're calling - sometimes you can even correct it yourself (ie. days suppy or vacation override), other times you can't fix it, but you know who can (Dr. has to call for prior auth) and on the mystery rejections you can call. If it's a refill too soon, we can say to the patient, "Come back on Wednesday."

A couple of third party plans have automated systems for vacation overrides, but usually there's a rep on the other line who can see the reject based on the script and cardholder ID number. They usually know what's going on before you even finish telling them. I think these people are generally helpful, even as third party is often too much of a barrier to health care.

Everyone in my pharmacy calls insurance - even the pharmacist. We all work together to get the job done - parking is not allowed.

 

[McZyprexalynn]

I think we call insurance companies maybe 10 times a day on a busy day, so that would be about 1 out of 40 prescriptions or so. If you're good with processing insurances, you'll rarely have to call the help desk. All insurance processing is done online and if you can get their computer to accept your claim, you don't have to call them. Once you've been around for a while, you get used to different insurance companies and their reject messages and usually don't have to call to resolve them.

90% of the calls I make to insurance companies are to get an override of some sort - usually a vacation override or a dosage increase override. The rest are either to find out what incorrect DOB the insurance company has on file for a patient (this happens more often than it should) , to find out what a patient's ID number has been switched to, or to check on a prior authorization. I rarely call on "coverage no longer active rejects" because all the help desk will tell you is the date that coverage ended, and the patient is still going to have to get it straightened out with their employer.

Typically you go through your typical press 1 for this, 2 for that menu, and eventually end up with someone on the phone. The conversation usually goes something like this:
Ins: Hi, this is Shaniqua, operator number 1234. May I have the id# of the patient you are calling on.
Me: 123456789
Ins: The patient's name and date of birth:
Me: John Doe, D-O-E, date of birth 1/1/1950
Ins: Your NPI number?
Me: 987654321
Ins: The name of the pharmacy?
Me: Walgreens
Ins: Your name
Me: McZyprexalynn
Ins: The first initial of your last name?
Me: X
Ins: Thank you, McZyprexalynn, how can I help you today?
Me: Yes, I need to find out if Mr. Doe's insurance offers a vacation override. He is visiting us and forgot his medication at home.
Ins: Ok, what is the prescription number in question?
Me: 55555
Ins: The name and strength of the drug?
Me: Fluoxetine 20mg
Ins: Okay, let me look that up. Can you hold for a minute?
Me: Sure
(after a minute)
Ins: Okay. I have put in an override. I'll stay on the line while you resubmit the claim.
Me: It went through now! Thanks!
Ins: Is there anything else I can help you with.
Me: No, that's it for now.
Ins: Well, thank you McZyprexalynn. Have a nice day. Goodbye.
Me: Thanks, you too, bye.

Sometimes you can get answers from the automated system, but most of the suck and don't understand what you input.

It's not that painful, and it should be handled by the techs. A pharmacist really does not need to do the calling unless you're at a slow store without a tech or something.

 

[RxWildcat]

That is why we have pharmacy technicians. I have never called an insurance company as a Pharmacist......

Why?

 

[MountainPharmD]

Why?

Why what.....

 

[RxWildcat]

Why not call the insurance co? Do you just always have enough tech help? If so I'm jealous, RA definitely skimps on the tech hours.

 

[MindOverMatter]

McZ explained it very well. It's very routine and nothing glamorous. A technician job would shed light onto these issues tremendously.

 

[rxlynn]

Every once in awhile, you will have to call the insurance company because your patient is stupid and won't take your word. Example: you get reject that patient's coverage has expired. Patient claims to have no idea why this would be, insists that they are covered and start screaming. So, that conversation tends to go like the following: You do all the stuff that McZyprexa talks about, you tell the insurance person the patient's story, and then they of course tell you that patient termed on such and such date, and they see no other coverage. Sometimes I'm tempted to just fake the whole phone conversation with the patient standing there, because you pretty much always know what the answer is going to be.

Another of my favorites is the patient who doesn't have their card, but insists that they have coverage under, say the State Merit program. Now, we have enough of those patients that I know which company processes Rxfor them, and I know what group code to use - the only thing I don't know is what is their correct id. So, every once in a great while, I get to call the insurance company and when they ask me for the ID # I say "Well, that's the problem I'm having here..."

Honestly, after doing this for quite a few years, it's given me new insight into how stupid many people are - would you leave your house without your current driver's license or your cell phone? Then why don't you have the right insurance card? ok - rant over