I had a office call me back on a PA. She gave me the number Medicaid gave her. I run it through the phone system. Ok. Ran the script. Came back DENIED.
If medicaid DENIES it, why the frick would you give it to me? You chose to write for Ortho-Tri-Cyclin DAW, you either get the PA or take off the DAW, not give me a DENIED number and let me have to tell the patient that I can’t magically make it work.
Oh and do all this at 2 mins to 5 so you are closed when I try to call you back…
Medicaid does not cover Brand name without a PA. EVER. (few notable exceptions). You know it, and I know it. I noticed right away that it was DAW and informed the patient about the PA.
Your office didn’t. Why? Cause you don’t want to tell them bad news? You’ll tell them they have cancer, but you won’t tell them that it might be a week before your office staff bothers to retrieve my fax and actually do something? (after sending me a “+6 refill OK’d” or three.)
I’m the one who has to cover for you, take your flak for you writing stuff thats not covered.
If your Patient wants DAW, and you write it, why not just get the PA BEFORE that script leaves the office?
Tags: Doctors, Frustrations, Insurance | |
July 23rd, 2008
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lb969cpht |
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Got into work. Pharmacist went to fill a script for Prilosec OTC. None on the shelf.
Asked our inventory person. Said they had just filled it yesterday.
500 bucks worth of Prilosec OTC stolen. Cosmetics girl says she saw two guys hanging out around her section messing with item tags. (They sometimes move tags around to demand the sale price on non sale goods)
Say she later sees em rush out with a backpack and the alarm goes off. They cleaned up and found tags for a brand of backpack the store sells.
I hate shoplifters…
Second was an insurance reject. Insurance company says it was filled at a pharmacy in Puerto Rico. I live in New York.
Called patient. She used to live in Puerto Rico with her sister, until she moved up here. Her sister, lives in Puerto Rico.
Here’s where it gets interesting. Her sister shares her first and last name. Just different middle ones. The insurance company has our patients address on file Puerto Rico…
Apparently they only overlap on one medication, and her sister has been using her card for almost a month without anyone noticing…
I love insurance companies….
Tags: Frustrations, Insurance, People | |
January 29th, 2008
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lb969cpht |
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That describes half my customers right there.
First is a druggy. Comes in for CII painkillers. RX has been stickered on the back by a local competitor and has the markings “NYMed Restricted” on it.
Wonderful. Allow me to explain
The Recipient Restriction Program (RRP) is an administrative program whereby selected recipients with a demonstrated pattern of abuse or misuse of Medicaid services may be restricted to one primary medical provider (physician or a medical clinic), one inpatient hospital, pharmacy, and/or to one dental provider and one DME provider.
This program has two major objectives:
1. To provide recipients with coordinated medical services which in turn improve the quality of their care; and
2. To reduce the cost of health care through the elimination of inappropriate utilization behavior by Medicaid recipients.
There are medical and non-medical reasons for a recipient to be placed into the restriction program.
The medical reasons include the receipt of health care services or supplies that are:
* duplicative,
* excessive,
* contraindicated, or
* conflicting.
The non-medical reasons include:
* forged prescriptions or fiscal orders,
* the possession of multiple Medicaid cards,
* card loaning and/or sharing, and
* the selling of drugs or other supplies obtained from Medicaid.
So the guy has been double dipping, and finally got caught. Well we’re just glad he went to the competitor first, as we’re not online with Medicaid yet due to “clerical errors”, and wouldn’t have been caught by the system.
He was good about it, didn’t get mad, just took it and left to go to another pharmacy. Apparently he does this with new pharmacies in the area often. He’ll go to multiple doctors, and get multiple painkiller scripts, and fill them at multiple pharmacies. All cash of course.
Second was worse. Lady is Hispanic, and doesn’t speak fluent English (imagine that).
She’s had prescriptions here before and they were covered on her Medicaid. But “happy birthday” she now has part D. Well, she swears up and down that she doesn’t. I even dialed the number and let her listen to the message. “Medicare Part A, and B, ad D”.
No, no she doesn’t. She just wants to take her medication and go. I tell her, sorry, I have to bill Medicare Part D, I can’t just bill Medicaid anymore. She proceeds to throw a temper tantrum for the next 15 mins while I attempt to get her plan figured out. She has no card (that she wanted to show me) and is generally rude. Interrupts me frequently while I try to contact the insurance, and chews me out for calling while I should be giving her her meds.
Finally she gets fed up and demands the scripts back. I can give back 2 because they’re new and haven’t been filled. but she has 6 refills worth about $800 cash. (they had been cashed out the day before when we verified eligibility)
So she goes to our competitor and tries to get it there. They call to transfer the Rxes. Then they call back a few mins later asking if I knew what her part D plan was, I gave them the info that I had managed to get from the system, and wished them luck. I managed to get her plan working in about 10 mins on the phone with the insurance company. Why bother? Because some are controls, so she’ll have to come back sometime if she wants her good stuff.
Tags: Druggies, Frustrations, Insurance, People | |
January 13th, 2008
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lb969cpht |
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Yeah right.
Starts off first thing in the morning. Computers are in local mode. no connection to Central.
Also no internet.
So no electronic adjucation with insurance companies. And no copays.
Oh joy.
I get a call from the help desk. Now there’s a misnomer. She calls and says “We recieved an alarm overnight that your stored went off the grid, and we can’t access your network remotely. And you Sat-backup isn’t working.”
Well yes, the DS3 line is out. No bypass on that, its a dead end. As the the Satellite backup? Its in a box in the closet. No, not a server box, a cardboard box. Its never been installed. I’ve opened a number of complaints about them never installing it when we built the store, and every time Tech support has been on site to hook it up they never know anything about it.
Now comes the rush. Busiest day of the year for pharmacy or so they say. I don’t think they mean in sheer numbers, its all the crap the customers pile on you.
First, everyones new insurance takes effect on Jan first. Well since thats New Years day, we’ll all go tomorrow. (yesterday was SLOW despite the fact we were open. I did all my inventory out-of-dates, and still had free time)
Next is the fact than many don’t bother to inform you that the insurance has changed. So you go and bill it and it gets rejected, then their mad at you that its not done when they get there.
So about 11 I get back online. Finally copays are generating. Well now all these claims are coming back rejected, or with errors.
Oh joy.
So I get this woman from Texas with a Blue Cross Blue shield card. Looks simple right? TXBC as the planID. Nope.
Its Express Scripts. and the card doesn’t have a bin or PCN number on it. Just a phone number for pharmacy services and the ESI/Perx logo. So I put in the ID number and bill to ESI/Perx.
Rejected.
Messed around with it for a while and then called the company.
Yeah, the member# on the ID card? Not the same as the Prescription one.
Takes this woman 10 mins of searching to tell me this. Takes her another 20 to actually FIND the number I need. This is all after spending 5 mins working through all the freaking phone prompts to get to a live person.
Lastly this old guy comes in. Speaks very little English. one of my techs handles him as I am getting ready to leave. This tech is rather new to pharmacy, and tries to fuddle her way through things she doesn’t understand.
So after her muddling through and not having any success, I take over. Yeah, its Medicare part D. Yeah he doesn’t have the new card.
He gets pissed and leaves because as he stated “It take too long, come back tomorrow, better not have problem”
Finally get it to go through. Half are too soon. The other few are rejected for various reasons.
Finally about 15 mins after I’m supposed to have left, I finally tell her to just put them in a bin and I’ll worry about it tomorrow.
I just LOVE the new year.
Tags: Frustrations, Holidays, Insurance | |
January 2nd, 2008
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lb969cpht |
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Spent an hour on the phone with 2 insurance companies. First tells me exactly what I need to know, but can’t help. this takes maybe 10 mins. Argent Health is good about service to pharmacies. She even connected me to the company I needed to contact and exactly what to tell them.
The second company is not so great. She has no idea what the other company is talking about. After 35 mins of telling this woman, that yes, indeed he HAS been getting $1.00 copays, she finally tells me that she will check on a different profile, and see what that says. She goes off for 10 mins, and finally comes back with “Oh, yeah, we took his L.I.S. off.” L.I.S. is Low income Subsidy.
Ugh. He got this LAST WEEK. So after another 5 mins of badgering, I get her to put the L.I.S. back on, in exchange for informing him that he NEEDS to switch to the generic from now on, for low cost prescriptions. No more brand name Norco for him.
The next is a drive-through customer. She hands me a card. I run it through and get every error in the book. Unmatched cardholder, invalid recipient, invalid group number, Check DOB, etc. After getting that all sorted out, “Claim submitted Prior to plan activation”. Wonderful. Its her NEW card for 2008. I ask her for her other insurance card. “But thats my new one. I don’t need the old one so I cut it up this morning when that one arrived.”
WONDERFUL…. New insurance plans go into effect January 1st, so you need to keep your insurance from the previous year until that date. Tried to explain this to the woman, but she wouldn’t believe me. “No, they sent me that new card, the old one doesn’t work anymore.”
So I ask for the company that she used to have. Its the local blue cross. I ask if she had a family plan. Yes. So I asked her for her husbands cell phone. I called her husband. Thankfully he understood that the new insurance goes into effect on Jan 1, and still had his card.
Third was a medicare part D plan. I alluded to the new Protonix generic, pantoprazole, in the previous post. As expected some plans haven’t added it to the formulary. One of my techs spent 15 mins monkeying with this guys plan because it was telling her that the drug was invalid. Switched it to the Protonix, and it charges him the brand price.
Wait, what?
Yes, it tells us that the generic isn’t in the system yet, but the brand has been bumped up to the non preferred list? So I called and badgered them into giving him the old price.
I loath most insurance companies.
Tags: Frustrations, Insurance | |
December 26th, 2007
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lb969cpht |
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