THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Friday, June 28, 1996 TAG: 9606280013
SECTION: FRONT PAGE: A14 EDITION: FINAL
TYPE: Letter
LENGTH: 49 lines
As relates to ``managed care,'' the following scenario is played out daily in community pharmacies, be they part of a ``chain'' or ``independent.''
A friend of an elderly patient (of 27 years) who doesn't drive came in on April 18 to get a prescription of an acutely needed medication.
I submitted the claim electronically to her insurance company, which denied the claim, saying the refill was early based on the last refill with different directions (thus different ``days supply'').
I called the processor to request an ``override'' and was told the insurer handled this directly (not the ``norm'') and was given another phone number to call.
I called the number and relayed the request and was told this number did not handle such matters. I was given a third person to call, which I did, but it was after 4:30 p.m. and the recorded message said one must call between 8:30 a.m. and 4:30 p.m. (healthcare is a 7-day, 24 hour a day endeavor that ``managed care'' often insists on controlling on a five-day, one-shift basis.)
At this point I sent the patient's representative from the pharmacy with the medication and told her I would pursue the fiscal aspects of the matter the next day.
On April 19 I called the third number and was told they did not handle such requests. I called phone (NU)1 back and was assured that phone (NU)2 was indeed correct as given the previous day, so I called phone number (NU)2 again, this time eventually getting a person who issued an override-authorization number.
Armed with this, I double-checked my software vendor on the format for the inclusion of the authorization number in my resubmit of the claim. The software confirmed my planned method, I resubmitted and was compensated a grand total of $4.36 for all aspects of the entire process, an absolutely ludicrous figure.
At this point I had (1) paid for two electronic transmissions to the insurer (they assess this cost to the vendor/provider, instead of bearing it themselves), (2) made six phone calls to 800 numbers that I pay for in whole or part, directly, or indirectly (I won't elaborate on the phone menus, button pushing, time on hold that occurred nor the investment of my time), (3) provided continuity of pharmacist-care to a long-term patient who through no fault of her own ``is not paying her way.''
That brings to mind cost shifting, and that's a story for another day, if we're still here.
J.G. ``JIM'' BLOUNT
Pharmacist
Edenton, June 16, 1996 by CNB