I don't know much about the medical insurance side of things, except that medical offices dedicate a whole staff of people just to work on insurance problems. They send the bills in, and you get an EOB (explanation of benefits) either in the mail or online. I assume in between times there may be some phone calls and e-mails sent back and forth before the whole kit and kaboodle is hashed out and finalized.
Now step into the "Jamaican Airlines" of the medical world. Remember the show "Living Color"? They had a skit with a family running an airline, and they all had about 15 different jobs: '' I'm the ticket agent, the baggage handler, the stewardess and the pilot! You are only the navigator? You don't have enough jobs, you lazy lima bean!''!
As your pharmacist, I am the greeter, the phone answerer, the question taker, the recommender, the counselor, the prescription taker, the profile updater, the insurance or coupon enterer, the prescription enterer, the insurance problem fixer, the prescription filler, the prescription checker, the prescription bagger, the prescription filer, and the cashier. I also run the drive-thru (2 lanes), do what the store manager tells me to do, put the drug order away, send the drug order for the next day, fix the printer, the cash register, and the computer. Oh, and I am often the bearer of bad news (don't shoot the messenger !). Theoretically I am supposed to have technician help, but it is often non-existent, at lunch, break, or out for an appointment, or incompetent. Rarely do I have a full staff, if any staff at all.
Here is how this process works. You go to see your doctor and receive a prescription carefully selected to treat your particular problem. You bring the prescription to me, and hopefully present your current insurance card (not last year's, your Medicare Card, your AARP discount card, any other discount card, or handwritten numbers on a slip of paper). I will enter the prescription and run it through the insurance. If the numbers are correct, and the planets align, and we keep our fingers crossed, I receive a paid claim. Visions of glory and angels singing, HALLELUJAH!!!!
The relief and happiness may be short lived. I have to tell you the copay, and if it is high, or the drug is not covered , or it needs a PA (prior authorization), woe unto me. And you. You have spent most of your day at the doctor's office and have waited for me to process your prescription, only to find out it is more than you can afford, or not covered at all. This tends to make you frustrated and angry. I get that. This is why we cringe when we have to tell you how much your medication is going to cost. This is why I may get a little short with you, because I have had this happen time and time and time again, for hours, days, and years, and it never changes. I want to help you, but I have no power to do so. All I can do is contact your doctor's office (who is probably at lunch or gone for the day by now) and/or your insurance company's pharmacy help desk. This takes time, and you are already tired and probably not feeling well. The stage is set for yet another unpleasant encounter between the two of us, when neither of us are to blame and the people who are sequester themselves so we can't strangle them with our bare hands.
What can you do to make this process less painful for both of us?
1. Insist that your insurance company send you a new insurance card at the beginning of the year. I believe that insurance companies should have to pay a fine for every day they do not get the insurance cards in their customers' hands. Tell them a piece of paper, or worse, having to call them and have them read the numbers over the phone, is just not acceptable, especially at the beginning of the year. If they refuse, get your HR person or boss involved.
2. Try to read your booklet and familiarize yourself with the basic copays for generic and brand name drugs. No, you will not understand it all, but it may help you get the general idea of how it is supposed to work.
3. When you do get a new card, please please please shred the old one. Then tell us it is a new card so we can compare the numbers to what we have in your profile.
4. If there is a glitch, give us both a break and come back later (at least an hour). We will make some phone calls and try to resolve the issue. Sometimes (but not always) we can give you a few doses to start with until we can get the insurance fixed. We understand if you are sick and really do try to get you going as quickly as we can but we can't break laws and we can't give away expensive medications. We also can't control how busy we are at the time.
5. If your insurance company requires a prior authorization, this means they want more information from your doctor. Either the medication is expensive, and there is a cheaper alternative, or there is a perceived conflict with one of your other medications , or they have some other reason they don't want to pay for it . Simple as that. While you are welcome to pay cash, if you want them to pay for it , we are going to have to jump through the hoops. We will call your doctor's office and give them the phone numbers to call and the message the insurance sent back to us. After this initial contact, the ball is in their court. Some offices are very good at getting PA's and some are not. If yours is not, you may have to call them several times. We can call them, but they do not hurry for us, either.
Like all the other things we do, insurance problems require time and patience from both of us. We are not your enemy. Give us a chance so we can help!
BP
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