It sort of annoys me that PBMs dictate what they pay for, when they pay for it... and in some cases whether or not the claim will process based on whether or not your reason for them honoring you and the patient with an over ride is good enough. PBMs are basicly already screwing us, right? They dictate the reimbursent. So why are we such slaves to them? Well, it all goes back to a long history of our (retail pharmacy's) submission to them.
I got into a spat with a PBM agent today. The patient was new, brought us a RX that was for a huge amount of Percocet #300. I called the doc's office to verify the amount, but I was also informed by the lady at the office that the doc was in a different office and she had to call it while i was on hold to get the amount verified. She then gave me the doc's other # in case there were further questions.
So I went ahead and attempted to process the claim to the lady's medicare D. It was an odd Med D, Id never heard of before, Goldsomethingorother, it was processed by one of those places that cannot really do much, so then you call the plan directly, you may know the drill.
The claim did NOT process and came back 1 day too soon. We told the patient and she said that she was now taking #12, instead of #8 a day. She phoned her insurance company using the # on her card and told us to talk to "Rose" and they would over ride the RX.
So I called. The PBM that processed the claims pays the claim and knows the day supply, so you'd think they'd know what sig was on the RX they paid last month, right? I called the given # and asked for Rose, but Rose was on another call, so i spoke to some one else. This person told me the patient had received #210 Percocet for a 27 day supply on 8/22/07.
I told her my RX is a #300 for 25 days and that the customer said they would over ride it for us.
the PBM agent says "well did you verify the increase in dose with the doctor?" I had tried to call the doc at the # the person at his other office had given to me, but could only leave a voice mail, no one answered.
I said "well no. the customer said you would over ride it, so I called you."
"well did you call the other pharmacy?" she says
"No, i don't know where she filled it." I say
"I can tell you that. she got #210, a 27 day supply 8/22 at Rite Aid."
"Oh good" I say, "then you can over ride it? This is a 25 day suppy for #300"
"Oh call Rite Aid, then call back and we will over ride it" she says
"Wait a minute! you want me to call Rite Aid, verify the info you just gave me and call you back? Why would I DO THAT?!" I say
"well you need to verify if the sig is different"
"You just told me the day supply!"
"I cannot see what the sig was" she says
"If you care so much why don't you call? I'm just processing the claim through to you! She is your client and frankly i don't care enough to spend this much time on this calling you, calling the other pharmacy, then calling you back, when you could call and do the over ride all at once.!"
"Well you should care! she is YOUR patient and if you want her to get her medication you will make the calls. but if you don't really care that much, as you say, than don't do it" she says
"Fine!" i grumble "whats Rite Aids #?"
Can you believe that crap?! To make a long story short I did waste my time, I called Rite Aid, AND I called this Goldsleiger Med D place back and was transferred 3 or 4 times until ultimately another agent at the plan said "we cannot do an over ride for a narc without doing a utilization review. I cannot imagine any agent would have told you (the story above), but I apologize. We have to contact the doctor and get the over ride. Well call you when it is auth'd"
Good lord! luckily the patient was pretty understanding, but what a waste of time for a RX.. at least we made $50 on it. If I had wasted all this time for like 23 cents Id have been really annoyed.
Tuesday, September 11, 2007
Subscribe to:
Post Comments (Atom)
4 comments:
who needs 300 percocet? what kind of condition requires 12# of those suckers a day. anyway i hate when you get some csr who just does not know what they are doing or how to help you so they send you on some wild goose chase that has nothing to do with what you want or need. i always want to write down their name and complain but i never remember to, or feel like dealing with some push button system to get to person that isn't going to do anything about it anyway.
Yea, I did inquire about the condition. Apparently, a back problem, according to her doctor's office, for which she is having surgery next month. Now why in the world would you not put a patient like that on oxycontin or fentanyl patches is beyond my understanding. I hope she has a healthy liver. She was really young... and already on Medicare, and she looked pretty able bodied to me, but looks are deceiving sometimes. She didnt seem like a drug seeker, but Ive never dealt with her before and she had never been to another pharmacy in my chain, at least under the name she gave with her DOB.
Couple of things I want to point out for you that you may or may not have realized by now.
First, your "patient" is actually a drug dealer selling those percocets at $5 a pop on the street.
Second, You did NOT make $50 on the script my friend. Sounds to me like to spent somewhere in the neighborhood of 20-30 minutes making phone calls and arguing about things, plus the time to actually process and fill the RX once you got the approval. Then count the loss/delay of the other RX's you could have been working on during all this time, and you're most likely at a loss.
PBM's do NOT save any healthcare wasted costs, they actually ADD their own waste to it, and the savings (rebates/kickbacks) that they do actually make, they keep all to themselves.
I agree, Joe, with what you say about PBMs. I don't agree that this woman was a 'drug dealer'. It's a possibility, but she didn't seem the type. I couldn't make a judgement like that based on this one encounter with her, without some other 'evidence' to support that theory.
Post a Comment