When pharmacists process prescriptions we submit an on-line claim to the patient's insurance plan (their very OWN individual plan -- that's why we need that CARD). Anyway, the claim may be rejected for a variety of reasons, many of which are fix-able without too much difficulty and some that will most certainly cause a delay, like "DRUG NOT COVERED." The insurance company's computer will give us some sort of short message which is meant to explain the reason for the reject.
Pharmacists know that sometimes these messages make sense and sometimes they are complete gibberish. Sometimes the reject message has absolutely nothing to do with why the claim is actually being rejected. Either way, a call to the insurance company is needed while the customer waits -- sometimes understandingly, sometimes not.
A recent example; refill for nine Ortho-Evra patches. When used as directed, this is processed as an 84 day supply (one per week for 3 weeks per month). My reject said:
"Plan limitations exceeded. Group LIMIT DAYS 84 per 84 days, 0 LEFT."
The only thought I could come up with was, she gets the first 3 months at retail then has to use mail-order? What does "0 left" mean? We're not dispensing 84 per 84 days..? Call to insurance, on hold awhile --- turns out it's a simple 'refill too soon.' Maybe "Refill too soon, next fill date XX/XX/XXXX" would have been a better message for us to have received.
Then there was the ever popular "Missing/Invalid Cardholder ID/BIN/PCN." All information was entered as on the card. Patient was sure it was current information. We try a few different things. Customer is getting tired of waiting. Technician navigates the insurance company's phone system, finally gets a person. Long story short, it's got nothing to do with the cardholder's ID/BIN/PCN. We're trying to fill a script for Azithromycin 500mg -- 1 tablet a day for 5 days. That's 5 tablets --- his insurance will only pay for 4. I dunno, maybe a reject message like, "Plan limitations exceeded -- max 4 tablets" or something like that might have saved us a lot of time? -- call me crazy.
One of the pharmacy magazines (I forget which) has a feature where people send in illegible prescriptions to see who can figure out what they actually say. Maybe they could do the same with some of these insurance rejects.
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3 comments:
So, what's the patient to do about the fifth azithromycin 500 mg? Do they have to pay cash, or go back to the doc for a sample, or go on the internet for one of those no-doc orders, or get another script for one more tablet after four days, or just go on home and figure that after a week or two if things go in a downward spiral after that, then they should go back to the emergency department? In effect, what has the insurance company told the patient and doctor and you about how to fill the prescription?
Our state medicaid likes to give you a reject saying "Drug Requires PA" on things such as HCTZ, Lisinopril, etc... then you call and found out in reality they're restricted to a particular doctor. Of course it would be too damned easy to just say restricted patient on the reject, now wouldn't it?
Just in response to the question from 'anonymous' above: What has the insurance company told us? -- Basically, "we call the shots." That's how it is. The patient paid cash for the 5th azithromycin tablet (which in the end is the easiest way out for everyone, including, obviously, the insurance co.) If we did the 5th tablet as a 'refill' he would pay another copay and have to make another trip in. At this point, he just wants to go home.....
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