Ugh, I hate our fucking system of healthcare, or should I say lack of system...

[Humanist_Activist]

we don't have a system, we have a means to increase profit for insurance companies at the expense of other people's life and health.

I work for a Prescription Benefits company, a middle man between insurance companies and members and pharmacies, we don't take your premiums, we don't set policies or copays, but we do hear about it from both ends.

So I have to blow off some steam because I took a call from a concerned mother, she needed to pick up a prescription for her son, and they were going to charge her 80 dollars. From what she told me, last week she tried to get his medicine for 90 days supply for 80 dollars(2x 30 Day supply copay), but the pharmacy didn't have all of the medicine in stock, so they gave her 20 days supply, which was charged at 40 dollars. This week she goes back to get the rest, and is shocked that it is an additional 80 dollars. Her plan does not pro-rate copays, if its submitted at over 30 days supply, its charged like it was 90.

So instead of paying 80 dollars(still an outrageous sum, in my opinion) for her son's medication, she has to pay 120 dollars for the same amount of medication. The issue is that this wasn't explained to her by no one, not the pharmacy, we weren't informed, and her plan didn't specify it in her paperwork. So she bursts out crying on the phone to me, no cussing me out, or even being angry, just despair, because money is tight, and she just wasted 40 dollars.

The kicker is that this is for her son's insulin, so its not like she can just have him not take it for a week or so to "stretch it out".

I know this is but one ancedote, but the fact is that, for the many years I've worked this job, I get at least 1 caller a week that is in some type of situation like this, they need a medicine, and because of insurance company or pharmacy shenanigans, they can't get it when they need it, it also happens to be absolutely necessary for their continued existence, I'm not talking about men complaining about getting Cialis only 4 times a month, but people needing clot busters after surgery, insulin for diabetes, etc.

Also, I know that I sound incredibly selfish in complaining about taking these calls, but honestly, sometimes, I just need to vent.

[Ms. Toad]

1. What normally happens in cases like that

is the pharmacy gives her what they have, charges her for the full prescription, and she comes back later when they restock for the remainder without additional charge.

That happens to us all the time, and as long as the doctor has written the prescription for 90 days we have never been charged a second co-pay for the remainder of a prescription (unless WE asked for it to be split).

I hope you gave her information as to how to appeal. In situations where the additional charge was not the fault of (or under control of) the patient, every insurance company I have dealt with waives the "error" the first time, gives a mild scolding, and warns the patient that next time the additional cost will not be waived.

ETA - we are a HEAVY user of medical care ($60-$120,000 a year) and have dealt with three mail order pharmacies, and about a half dozen insurance companies since we became such heavy users. Some are more difficult to navigate, but ultimately they have all had the same practice: Initial refusal, customer support that is not helpful - which uniformly knows less about the rules than I do (except for Medical Mutual has exceptional customer service, in my experience), insistence that an appeal is the only option (and in this case it probably is), and an appeal, followed by waiving the fees with a warning never to do it again.

[Humanist_Activist]

2. Yeah, its a retail pharmacy, and I told her how to appeal, and file with her insurance company...

for reimbursement, she calmed down after that, plus you are right about the pharmacy, they should have done what you suggested, but they didn't. Note, one thing I found out, most of the billing done at pharmacies are done by techs, and most of them either are stupid or apathetic. In many cases they will lie to customers about their insurance coverage, I get customers calling, pissed, all the time, about how they paid full price for a medication because the pharmacy told them they don't have insurance, and I have to tell them the pharmacy mis-typed their ID number and then never followed up on that(no call records).

The thing I hate is that I'm powerless in these situations, and I hate passing the buck, but I'm simply either don't have access(like adjusting copays) or don't have authority to do some things(like certain overrides). I'm allowed to do some things based on my own judgement, but frankly, if I had the power(and didn't care about keeping my job), I'd make all copays 0 dollars and override damn near every rejection(except those of obvious abusers trying to get Xanax 3 times in a month).

[Ms. Toad]

3. Your last paragraph -

is why I said in this case appeal is probably the only option.

What I have run into are places where the insurance company has screwed up - like when I have obtained pre-approval for something but they miscoded it and send it to the separate corporate entity which deals with out of network claims. In those instances (when there is an insurance screw-up, rather than pharmacy or doctor) I just work my way up the ladder until I reach someone who can fix it. I know tons of people won't go through the appeal because they figure the deck is stacked against them, and to some extent insurance companies count on that. I figure if it is their screw-up I'm not asking for special dispensation because of my or third party mistakes - and they should make it right without forcing me (or other patients) into appeal to correct their own mistakes.

In most instances, that means the first folks answering the phone still can't do anything - but when I can cite the rules and specifically point out their mistake, supervisors generally can fix it. So I insist they do so that perhaps they will learn something and not make the mistake for the next patient.

[Humanist_Activist]

4. Well, I'm after hour coverage, so asking to talk to my supervisor is difficult...

I do try to direct member's to the right people if there is something I can't do for them or answer for them or send messages to my administrators. It really varies, and being after hours, for example, today, means I'm by myself.

There are cases where our PBM screwed up, I actually like those, because in most cases there is a record in the system, and I happily take authority to fix the situation, usually correcting misapplied or mis-dated overrides in the system, or adding an override that someone failed to put in, etc. Note: I was never told whether I was allowed to do this or not, I just do it, as long as there is a record of it in our system, unfortunately I cannot take the word of either members or pharmacists on this. So far, I haven't been yelled at for that.

In most cases, the screw ups have nothing to do with us, for example, COBRA failing to renew member's prescription coverage, which is their insurance company's responsibility, not ours, we aren't in charge of that either.

We are contracted with hundreds of employers, unions, etc. with many different plan policies for each and every single one of them, its a pain in the butt to keep it all straight. Some plans give us a lot of leeway, others micromanage the hell out of things.

[Ms. Toad]

15. You're the kind of person I like to talk with -

Because my assumption is exactly that. If you can look in the system and see that the screw-up is yours, you ought to be able to fix it without forcing me to appeal. And the competent customer service reps all can with relatively straightforward ones (either directly, or within a week by raising it a level internally).

My experience must be abnormal, then. At least half, in my experience, are pure insurance company screw-ups. About 30% are miscommunication between the contract doctor and the insurance company. About 10% are purely idiot doctors. And about 10% are mine (almost exclusively because of changes in practices - like referrals which used to authorized for unlimited visits within a 6 month period being changed to only 2 visits within 6 months - a ridiculous limit for a chronically ill child who has been treated several times a year by the same specialist for 17 years).

I've had some real nightmares.

[Humanist_Activist]

16. Yeah, the only thing I can't do is base it on assumptions...

If I can see the documentation, I will try to help the best I can, but I may not have access to everything, so if I can't see any documentation, worst case scenario is that I will have to do nothing but send a message to my administration so that they are aware of the issue, and they are usually good and respond by the next business day or so.

[mahina]

6. Why I still love DU, #7653

So much real-world knowledge in so many good people.

I appreciate the OP and your responses. Thank you.

[gopiscrap]

5. No kidding I contracted a case of encephalitis when I was 6 weeks

old. I was born in Germany. I was in the hospital for 6 months the bill came to about 100.00 dollars. Fast forward....at 38 I got cancer a second time, in the US. My bill (as an uninsured individual) because I was dropped for having cancer the first time (this was before WA said hyou couldn't do that) came to 192K and we lost everything we had.

[mahina]

7. You don't sound selfish at all.

Thank you for sharing this window into our system. This system serves Wall street, but not patients, and certainly not doctors.

[Quantess]

8. Why would anyone call you selfish for complaining about these stressful calls you are taking?

What can you say to people in these situations? It sounds like it's not easy.

[Dustlawyer]

9. Hey man, thanks for the help that you can give! I am frequently on the phone for many prescriptions

I travel a lot for work and have to come back to Texas every 30 days b/c one prescription has to be hand delivered from the doctor's office to-me-to the pharmacy. Another has to come by mail order pharmacy to only pay $50 co-pay, except that I do not know my locations day-to-day so I have to pay $332, the full cost. I know its not the person's fault on the phone. I just get frustrated at the time, effort, and costs for things I know I will need for the rest of my life, that's the depressing thought.
Our whole system is corrupted from the bottom to the top, the people have ceded their voice to the wealthy. Our Health Care system is a product of lobbyist having their way with politicians who make the law. It is evident in the gist of Obama Care (a right wing idea for a reason) that health insurance companies were taken care of, Big Pharma was already taken care of, and we that can still pay have to pay through the nose. It would have to be cheaper with Universal Health Care!

[WillYourVoteBCounted]

10. yet we have unlimited $ for wars and banksters

its the truth.

Anyone deny that our govt is not representing US?

[LuckyLib]

11. All of these tales are tragic and point to a dollar-incentive system that screws everyone.

There is no reason for such bullshit with prescriptions. None. No co-pays, no games, no ignorant pharmacy clerks, no repeated appeals, no snow-jobs. No hundreds of hours spent untangling insurance screw-ups, doctor and pharmacy screw-ups, etc. We need single payer health care in which you walk into a pharmacy and get your prescription. End of story.

[spooky3]

13. +a brazillion

[Wounded Bear]

12. You're right, it's not a 'system.' It's an industry.

It's a corporate run industry, with financials being far more important than any health outcomes, except for those who can pay.

[pnwmom]

14. You're anything but selfish. You're taking the time to inform us of how the system

is NOT WORKING.

Thank you!

[Corruption Inc]

17. Yes, that 30 day supply BS is a racket set up to double/triple charge people

Just like most other things in the corrupted U.S. now.

[Ms. Toad]

18. You think that's bad -

I was on (self) injectible heparin, and we didn't know how long it would take to stabilize on an oral medication so the doctor ordered 5 syringes, followed by 2, followed by a series of 1...

They were classified as specialty drugs so I had a co-pay of somewhere between $90 & $180 (It's been too long - I don't remember which version of specialty drugs they were, but enough to hurt) for each order. I could have started out with 30 syringes (at a rough cost to the insurance company of $175 each - and thrown away the ones I didn't need), but was trying not to be wasteful of medical & financial resources.

It became was clear I wasn't stabilizing so I tried to negotiate a deal to save both me and the insurance company money (pay for a single full 30 days co-pay, accept a few syringes at a time, then just "forget" to go back and pick up the rest once I stablized). That idea didn't go over, but in the process I did find out that if I had just requested the full 30 day supply that I could have donated the unused (individually packaged) syringes to a charity care provider...that information came from an insurance customer service rep, and is exactly what I will do next time with individually packaged meds. Unfortunately, it didn't save me any pennies this go-round.