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

Utilization Reviews (UR) are used by health insurance carriers as a type of managed care to ensure that medical treatments are appropriate and efficient. Medicare may require a Utilization Review to verify that patient is not being over-prescribed pain medication. Worker's Compensation carriers may request URs to ensure that patients are not being over-treated by shady doctors. Your private insurance may require a Utilization Review to ensure that all first-line or recommended treatments have been attempted. Utilization Reviews are retrospective--that is it's a review of treatments that already have happened--but may be required before carriers provide prior authorizations for new services.  Utilization Reviews have strict criteria and rely on evidence-based evaluations. Your own doctor will submit the medical history, evidence, and recommendations and the insurance carrier will assign a neutral doctor to review the paperwork, evidence, and treatment plan before issuing their o