Recently, I spent over one hour to resolve an issue that should not have taken nearly as long as it did, nor should have been a problem from the start. It had to do with a patient who needed blood glucose strips filled. This patient uses an insulin pump, so she must check her blood sugars 7 times per day. The patient’s physician had completed the prior authorization paper work and the patient did receive a letter from the PBM indicating that the strips had been approved for coverage. And yet, when we went to fill the prescription, it got rejected because the product is an OTC. The PBM was called and their representative basically read to me the rejection that I was already seeing on the computer screen. So when I explained that the patient received a letter from them specifying that the strips are covered, the representative put me on hold and had to check her sources. After some time had passed, the PBM representative came back on the phone to tell me that they cannot provide this override as it has to come from the plan because it is an OTC (Over the Counter) reject. She then proceeded to tell me that I had to call the plan specifically as they would have to approve the override and she gave me the plan’s toll free number. WHAT?! The letter came from them (the PBM) to the patient, not from the plan! The PBM representative insisted that this type of reject has to be overridden from the plan. I repeatedly asked the PBM representative if the information on the strips could have been coded wrong, but she said, “No, it had to be overridden by the plan.” So I proceeded to call the plan.
The plan representative was confused by my call. She asked me if I had reached out to the PBM, and my answer was YES! I told her what the PBM employee told me, and this just added confusion to the plan representative who said she would have to put me on-hold. After some time she came back on the phone and she asked me to re-run the claim so she and another plan representative could see the reject. Once I ran the claim, both representatives were now perplexed on why the claim would not go through. The plan representative put me on-hold again and said she needed to do some more checking on why this claim was rejected. After some time, someone at the plan hung up on me. After some more time passed, I did get a call back from the plan representative who was very nice and helpful. The plan representative informed me that the error was on the PBM side; they had coded the information incorrectly from the start. Hmmmm!!! This is what I asked the PBM representative previously. So either the PBM representative was lazy, misinformed, or not trained properly to check or identify if the transaction was miscoded. Luckily, the plan representative was able to get into the PBMs system and make the necessary correction, and the claim did go through.
So, for those pharmacists who deal with these type of issues on a daily basis, they know exactly what I am talking about and the frustrations with these type of calls. This happens way too often and provides no value to anyone. The complexities of the system created by the PBM are even beyond the PBM’s help desk employees, and even they could not help us correct the issue they created. And who’s paying us to correct errors like this for them? Community pharmacists are being bombarded with underwater MACs, DIR fees , clawbacks, and insufficient reimbursement for many medications. And yet we are the ones who not only provide clinical services for our patients, but also resolve these claim processing errors.
If pharmacies are charged a fee by the PBM for each and every claim they submit to be processed, should not the PBM’s have to pay pharmacies for their work helping patients achieve their therapeutic outcomes–even if its to resolve processing errors made by the the PBM? Indeed, if it were generally known how much time pharmacies spend working on PBM generated problems like this, they would likely be appalled. If the federal government has rules to reduce burdensome paperwork, should not the contracts signed by pharmacies (and on their behalf by their PSAO) have language that covers time wasted by the phararmacy on the behalf of the processor. In this case, a pharmacy technician would have cost the pharmacy about $30 in time. Where should we send the bill?
This is a open call out to all contracting organizations representing pharmacies (chain and independent). As our partners, stand up for us. Emphasize the value of pharmacies in assisting patients navigate the difficult world of the pharmacy benefit. Help the PBM industry respect our time and efforts. In the past, reimbursement for product helped offset pharmacy hours spent working these types of problems. Current reimbursement no longer allows pharmacy this luxury.
Remember, from the beginning, this was a clinical issue. A patient with diabetes, with an insulin pump, requires testing above “normal” test strip usage. All of the obstacles were administrative, and in no way helped the patient. It took the pharmacist to uncover the convoluted mess created by administrative policy and clerical error. It is always about the patient–let’s not forget this, and this needs to be emphasized to payers and PBMs!