For this week, I will address the hidden costs of Healthcare Insurance.
For background, our office cares (over 97%) mostly for Medicare and Medicaid patients.
On Wednesday, the pharmacy of one of our patients faxed us a notice regarding a prescription. The notice was that the patient's insurance wouldn't cover this prescription. Usually that means the doctor must determine a different medication that the insurance company will cover. This time however, something else was in play.
Our physician wrote a prescription and the patient took the paper copy to the pharmacy.
The pharmacy attempted to bill the patient's insurance (which is a Medicare Part D plan through a private insurance company). The plan will only pay if the patient is receiving a dose from a single pill once a day of this particular drug.
The drug comes in 25 mg, 50 mg, 100 mg and 200 mg doses from the manufacturer.
Our physician decided that his patient was best served by a 75 mg tablet, one per day. Silly doctor, imagine him thinking that he should be the one to decide what kind (and how much) of the medicine the patient should be taking!
The only way for the pharmacy to fill this prescription would be to dispense 90 25 mg tablets, of which the patient would then take three doses per day to equal the 75 mg dose the doctor has ordered.
When I receive the fax from the pharmacy, I have to call them. First, I have to check the patient's electronic records and determine if there has been some sort of error on the pharmacy's behalf. I do so and find that the doctor has ordered a single dose a day, but of a 75 mg tablet.
The fax from the pharmacy is showing a dose of 25 mg tablet, and notation that the insurance will only cover a single dose a day, which is why the patient's coverage will not pay for the prescription as written.
This is patently wrong, as I have just checked, and our physician did, indeed, prescribe a single dose one time daily, I can look at an electronic copy of the prescription that was written.
-- at this point I have now spent at least 5 to 10 minutes --
Once I call the pharmacy, and get through their voice-address system which takes anywhere from one to five minutes, I get to wait on hold from one to fifteen minutes.
Finally, a pharmacy staff member picks up. I spend about thirty seconds describing the situation, when I am put back on hold to speak directly with the pharmacist.
-- at this point I have now spent at least 8 to 25 minutes --
When the pharmacist picks up, I have to repeat my explanation of why I am calling. The pharmacist tells me the situation of the standard doses available, and that the doctor's office has to contact the insurance company to get pre-approval for the three times daily doses of 25 mg tablets, due to the doctor's order for a non-standard dose.
Even though the amount of the dose was less than half as much as the highest dose available in a single dose (200 mg tablet) - which, theoretically at least, should be less expensive than that highest dose.
I attempt to disuade the pharmacist that this is an issue for doctor's office to deal with. It appears to me that we have done our part by writing the prescription. I feel that the pharmacy selling the medicine should deal with the insurance company. The pharmacist assures me that the insurance company will require that the doctor provide a medical reason why a pre-approval for this medication is necessary.
-- at this point I have now spent at least 20 to 35 minutes --
In frustration, as I see the calls now going to voicemail, that I will have to retrieve before answering them, I tell the pharmacist that I will have to call the pharmacy back after speaking with the doctor.
The next time I pick this issue back up later that morning, I actually call the insurance company phone number provided to me by the pharmacy. I get through the voice address system, and then sit on hold for 27 minutes waiting to speak to someone about this medication. Of course I am doing other things while waiting on hold
printing and mailing requested healthcare records, sorting incoming mail, processing in supplier billing invoices in Quickbooks, counseling a patient on the preparation for a test they will be having later in the week, taking patient co-pays and payments for supplements - all the while listening to the lowered sound of the holding muzack in case they actually pick up and speak to me
Everything except answer my second line, because I'm certain that someone will pick up my call soon, and if I hang up I'll have to start all over again, and it's been 14 minutes on hold already.
-- at this point I have now spent at least 47 minutes --
When I glance at my phone's Caller ID window and see that I've been on hold for 27 minutes and counting, I give up and hang up.
I am at the end of my patience, and cannot in good conscience continue to spend time on this patient's problem. In my mind that is exactly what it is, the patient's problem. Even I don't immediately label this the insurance company's problem, although I sure as hell should.
I speak briefly (less than one minute) with the physician (and take up some of his time on this issue now too), and here is the only solution that is reasonable for us.
I call the patient and let him know that for this particular medication there is an issue due to his insurance company and his limited coverage and the dispensing dose problem. I tell him that he can pay out of pocket, but if he would like to contact his insurance company, he can do so, but we cannot do anything else for him at this point. He seems perfectly fine with doing so, but I am fearful that in the near future (like tomorrow) he will be calling the office back, and telling me that the insurance company will not speak with him about this issue, and they have told him to have the doctor's office contact them to get the pre-approval that he needs for them to cover the cost of this medication.
-- at this point I have now spent at least 57 minutes --
Imagine this senario expanded to cover over 800 patients (which is our clinic's patient load at this time, although I must confess at least one third of that number are most likely single visit patients who will never return to our clinic).
This type of problem which I have described in excruciating detail here for you (with any information which could possibly identify the patient and violate the HIPPA regulations striped from the narrative), is more common that seems possible in any sane world.
The cost of that wasted time multiplied by the number of primary care doctor's offices in the United States is mind-boggling.
These types of problems should not happen. If the insurance company will pay for a single dose one time daily of 200 mg of a medication, shouldn't they be willing to pay for multiple doses of the same medication, so long as it is less than the maximum dose that they will pay for? Doesn't that make sense?
Welcome to Healthcare Insurance in America, where sense has nothing to do with anything.
See you next time around. I'm sure I'll have another story ready by this time next week, because the frackin insurance companies will still be there this week, waiting from me to call and waste hours of my valuable time holding......
