Patients are at the center of a complicated web...

Communication is key in any successful relationship but it's especially important in the world of healthcare.  Patients are at the center of a complicated web of providers, insurance carriers, third party administrators, pharmacy benefit managers, claim adjusters, and federal regulation.  The meeting between a patient and their trusted doctor is only the beginning of a long and complicated journey. 

Imagine a common healthcare scenario, such as a doctor's visit for a sore shoulder or an infected cut.  The meeting may last no more than fifteen minutes, but it sets off a complicated chain of events, navigating a system of payee/payor relationships, medical providers, and information processors. In the case of an infected cut, the doctor prescribes two antibiotics, a pill and an ointment, and electronically transmits prescriptions to the pharmacy on file. 

A new provider--the pharmacist--has just been invited to the relationship. Here a new series of complications is introduced: is this the correct pharmacy for the patient? Does that pharmacy have all the required information updated on file? Is the Insurance on file still a valid plan? What pharmacy benefits are available to the patient? Are both items in stock? Are the instructions from the doctor clear? Is the pharmacy open at that hour? If there is an obstacle at any level, the patient's treatment is delayed and the standard of care drops. 

Now imagine that cut came from a workplace accident. Perhaps the patient is a Debbie, a vet tech who was scratched by an irate cat.

She washed and bandaged her hand, but she did not report the injury at the time of the incident. When she wakes up the next morning, her hand is red and throbbing, and her finger is stiff and swollen.  She can't get in to see her primary care physician, but her insurance covers a trip to the Urgent Care, so she visits the nearest in-network office before work the next morning. They bandage and clean her wound and the PA prescribes antibiotics. She tells her boss she is picking up a prescription after work, but she has not met her deductible, and so she needs fifty dollars for the pharmacy copay. 

Debbie was smart to get treated before the infection got worse, but who is responsible for paying the pharmacy that night? 

Debbie believes she should not be out of pocket because the injury happened at work due to no fault of her own. She doesn't have a spare fifty dollars right now and she needs to start her antibiotics as soon as possible. 

Should her boss pay out of pocket? Is her supervisor obligated to give her fifty dollars that day? 

Is her personal insurance responsible? Even if they are, she has not met her deductible. Who will pay the Urgent Care, for that matter? 

Suddenly, a simple visit to the doctor's office is complicated by legal liability and payment.  

Debbie's shift ends at eight o'clock. Her pharmacy closes at nine. She gets there forty-five minutes before closing and the prescriptions are in stock, but fifty dollars is due before she take them home. 

Who does Debbie call? 

Patient Services Solutions will solve this problem. 

First, we will contact the employer to verify a report of injury was documented and the name of the insurance carrier who received that report. 

Second, we will verify the pharmacy benefit management (PBM) information, including BIN, PCN, and phone number to provide to the patient's pharmacy. 

Third, we will contact the patient's pharmacy before they close and assist with processing--including beginning the prior authorization process if necessary--and verify a positive outcome for the patient. 

When can Debbie contact us? 

Any time! She can call us before she attends the urgent care to verify the proper steps for a workplace injury. She can contact us after the prescription is sent to the pharmacy or when her boss tells her that she will not be reimbursed for her medications. 

That's just one way out of many we can help Debbie. Healthcare systems are currently overwhelmed by the number of patients and this additional strain on the system has made communication sparse and the process fraught with interruption and delays. 

We're here to ensure patients do not get lost in the mix. Please let us know how we can help you today.