Skip to main content

Why Won't the Pharmacy Help Me?

errors in paperwork can stop you from getting your medicine

 Each time a prescription is faxed, electronically transmitted, or brought into the pharmacy, critical information is being communicated from the doctor to the pharmacist. If any of that information is missing, confusing, or contradictory, the pharmacist will be unable to fill the prescription and release the medication to the patient. That information must be clarified. And yet, more and more, pharmacies are refusing to make the phone calls necessary to fix the miscommunication. 

In the past two years, pharmacies have been faced with a tremendous shift in responsibility. This is mostly due to the realities of the Covid-19 pandemic--care such as testing and vaccinations have shifted away from clinics and towards pharmacies. Pharmacists and pharmacy techs were named as necessary workers during the shutdowns, and thus, had an increase of exposure to the virus--this resulted in a depletion of the regular workforce overall. With an increase in responsibilities with a decrease in necessary manpower, many pharmacies have had no choice but to shift focus and this means they no longer make necessary phone calls, instead pushing that step off onto the patient. 

And yet, many doctors offices and clinics have not changed their standard operating procedure when it comes to handling prescription refills and clarifications. Many clinics will not even take calls related to prescriptions from patients, instead instructing patients to contact the pharmacies to start the process. 

What can a patient do when they are stuck in the middle? The pharmacy does not have the means to call the prescriber, and the prescriber is not going to reach out to the pharmacy on the patient's behalf. Neither will allow the patient to actually be the intermediary to solve this problem. 

But that doesn't mean that there is no option. 

We can help you. 

With your authorization we can reach out to the pharmacy on your behalf to learn exactly what information is missing, what message they have received from the insurance carrier, or what other obstacle they are facing. We can then use this information to ascertain the next best step, including reaching out to your doctor's office, your insurance carrier, or your claims adjuster or case manager. 

Don't let yourself be caught in this endless loop. Let us know what you need and we will let you know how we can help. 

Comments

Popular posts from this blog

What is a Third Party Administrator?

You likely know the name of your private insurance carrier and you may even know the name of your employer's worker's compensation insurance carrier--but what you may not know is that these insurance carriers have little to do with your actual claims.  Instead of doing the back-office work themselves, they contract with Third Party Administrators, or TPAs.  TPAs are responsible for a wide number of tasks. They may conduct Utilization Reviews for medication and medical procedures and issues authorizations or denials. They may handle pharmacy benefits, or contract directly with the pharmacy benefit managers (PBMS) that process the pharmacy claims. They handle all billing for medical providers, and pay those providers based on contractual agreements. The TPA may have complete control over every financial aspect of your private insurance or worker's compensation claim. Sedgwick or United Healthcare may be your insurance carrier in name only.  Insurance carriers contract with ...

In or Out of Network? Primary Care of Specialist? HMO or PPO?

 Throughout your life, you will change insurance carriers many times. Sometimes you lose or gain eligibility due to a career change. You may age into Medicare eligibility, you may marry or divorce, may choose to join a plan on the Healthcare Exchange, or may become disabled and eligible for your state's Medicaid or Social Security benefits. Depending on the type of insurance, you may be able to change your plan every year, or you may have to wait until you have a qualifying life event.  Each time your benefits change, you are faced with the same series of questions and considerations. Is your regular physician in your new network? Do you need to get a new referral to continue to see your allergist or cardiologist? Will your deductible be higher or lower? Are your medications still covered? What is your new copay for regular visits? Can you go to the emergency room if if it's necessary?  First it's necessary to understand the difference between an in-network provider (INN)...

Common Insurance Terms

Pharmacy Benefit Manager (PBM ): Third party companies such as OptumRX, ExpressScripts, and CVS Scripts that contract with insurance carriers and coordinate with pharmacies to process pharmacy benefit claims.  The Big Three process over 70% of pharmacy insurance claims in the United States and they they are not obligated to ensuring patient care or maintaining the standard of care. They promise to reduce costs to insurance carriers and profit from minimizing care to patients. Third Party Administrators (TPA) : Third party companies that are contracted with insurance carriers to administer claims, including adjust and adjudicate, guarantee payment, utilization reviews of medical and pharmacy authorizations, contract with providers, and accept or deny liability.  Claims: Payment requests from medical providers or pharmacies submitted to the responsible party.  Responsible Party : The responsible party for a claim is the person or entity legally obligated to provide payment...