Patient Services Solutions

 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

 Because healthcare is a complicated web of decisions and payments, the doctor's treatment decision is not the final word, it's only the beginning of the discussion. Medications are particularly vulnerable to denials for a wide variety of reasons, a few of which I will be discussing in this post.  The insurance who received the claim is not the appropriate payor.  This is a pretty common mistake that happens at the pharmacy level. Sometimes the information in the pharmacy system has not yet been updated, such as when an insurance plan expires or begins. Sometimes the pharmacy has multiple plans on file to choose from and select the incorrect option. Sometimes it's not clear if the medication is for personal, auto, or work related injury. As the pharmacy does not know they have submitted the claim incorrectly, they cannot necessarily tell you why the medication is denied. Before you panic, be sure to verify the information the pharmacy is using. Make sure that the plan infor

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 TP

 Pharmacy Benefit Managers coordinate between pharmacies, insurance carriers, and other third party administrators in order to  guarantee payment and process pharmacy claims. Pharmacy Benefit Managers are shortened to PBMs, and the number of claims processed by PBMs have grown exponentially in the past decade.  In fact, a PBM probably is responsible for processing the medications your doctor writes every month. And yet, you probably don't even know the name of the company that touches every one of your claims and stores your personal health information (PHI). Although PBMs are engaged in processing your medication they do not work for the patient and they have no interest in the standard of your healthcare.  The three largest PBMs in the industry are CVS Caremark, Cigna (Express Scripts), and United Health Group (OptumRX). These PBMs handle private insurance, medicare, worker's compensation, and auto no-fault.  Drugchannels.net estimates for 2020 ...The big three PBMs—CVS Heal

 

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 for services

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: i