The issue isn’t necessarily a matter of Medicare, it’s just insurance in general. For example, a customer at Main Street Pharmacy in Highlands came to have a prescription filled and was denied. Based on the information the pharmacy had on their computers, technicians couldn’t understand why.
They called the insurance company and it turned out that the company had the drug’s dosage improperly recorded. Workers at the insurance helpline didn’t know — they’re not trained in the medical field, all they knew was what the computer in front of them said.
The larger problem at hand was that the inaccuracy didn’t just affect the Highlands customer, it affected any customer anywhere that was attempting to have the same prescription filled.
Rather than wait for the insurance company to get its records straight, the pharmacy went ahead and filled the prescription and filed it against insurance later. If the insurance company hadn’t corrected their mistake, the pharmacy would have been out $150 on just that one prescription alone.
Improper coding is more rare than rejections based on non-matching information or prescriptions requiring prior authorization. Customers often don’t know when prior authorization is required and simply show up at the pharmacy, prescription in hand. When the pharmacist tries to fill it, their computer system puts a stop on the order.
“It happens about once an hour,” said Kim Cowan, owner of Eastgate Pharmacy in Sylva.
The pharmacist must then call the doctor who must in turn call the insurance company to say — yes, indeed the customer does need to be on the prescribed medication. The insurance company decides whether approval will be granted; if it is, the pharmacy is contacted and the prescription is filled.
Of course, the process takes time. Sometimes more time than customers want to wait. It isn’t counting out pills that takes so long for a prescription to be filled. It’s jumping through hoops.
“It gets real old after a while,” Cowan said.
Similar rejections may occur when insurance companies don’t want to pay for higher cost drugs. A customer with a prescription for the antibiotic Levaquin may instead go home with Amoxicillian — a bottle of 100 Levaquin may cost a pharmacy $600, while 500 Amoxicillian pills cost about $100, said Alecia Adams, a Main Street Pharmacy technician.
Getting the run around has forced many pharmacy workers to familiarize themselves with the way the system works beyond drug store walls. They’re the ones customers are asking — why can’t the prescription be filled, why does my insurance require prior authorization or not cover the drug at all.
Rather than frustrate customers further, they try to provide answers or at least direct them to someone who can. However, it is largely up to pharmacists to teach themselves about the new Medicare system — at least in the private sector. Large, corporate pharmacies such as CVS or Wal-Mart most likely provided training for making the switch.
“I was probably fairly naïve going into it,” Cowan said.
As an independent pharmacist, Cowan enrolled in continuing education programs to get more acquainted with the system. But really, it’s been one of those things best learned by doing.
Same goes for the insurance industry. A broker for 34 years, Floyd Rogers of Haywood Insurance Services Inc. in Waynesville balked at the new Medicare system when it first was unveiled.
“You might as well have asked me to fly a plane,” Rogers said.
The system is such an entangled bureaucratic mess, patient care has been put on the backburner, Cowan said. As an alternative, Cowan said he’d like to see insurance companies pay for all prescriptions at least once and then take the lead on getting customers switched over to something more cost-effective if need be.
“It’s bad, don’t get me wrong, but it’s what you deal with everyday,” Adams said.