Why Insurances Suck #244

CP: Thanks for calling Commiseration Palace, home of CP, Pharmacist du jour, how may I help you?

Nurse Is Calling Explaining Our Niggling Endeavour: I am calling about a prior auth you initiated with us. 

CP: Do go on. 

NICE ONE: I called and they said it doesn't need one. 

CP: Ah. My favourite game to play. I bill it and receive a one sentence reply: "prior authorisation required, have prescriber call 1-800-THATS-A-NO". I call you only to have you call them and have them tell you the pharmacist erred or misinterpreted our "prior auth required" message and that no such auth is required; prior or otherwise.

NICE ONE: Well, they did provide me with this alternative billing information to give to you. They said "provide this BIN, PCN, ID#, and GRP# to the pharmacist and it will go through".

CP: Sure. What the hell. Why not? 

<enters billing info as provided>

Well that worked!

NICE ONE: So it didn't need a prior auth?

CP: Yes. No. Wait. Hold on. What in the actual name of #PharmacyPhuckery just happened? 

NICE ONE: What is it?

CP: The card information you gave me? 

NICE ONE: Yes. What the insurance gave me to give to you? 

CP: Yes. It's not new billing for the patient and her insurance. 

NICE ONE: It's not? That's weird.

CP: No. <laughs> What's weird is it's actually a discount card from the manufacturer. Instead of paying for the medication or approving the prior auth, the insurance looked up a manufacturer coupon and gave that to you to give to me. 

NICE ONE: That's pretty lame. 

CP: No. That's pretty low.  

NICE ONE: That's a lot of unnecessary legwork for the both of us. 

CP: That's a pretty sardonic wild goose chase. Now I know the insurances are just messing with us. Must be today's game on their desk calendar. 

NICE ONE: How to phuck with the pharmacy and prescriber?

CP: Indeed. 

NICE ONE: I can't wait to see what tomorrow brings. 

CP: That's why I get out of bed in the morning; to see what fresh hell pharmacy, insurances, prescribers, and patients have dreamt for me over night. It keeps our one-sided masochistic relationship phresh.

                                

You Cannot Help Those Who Will Not Help Themselves

I can explain it to you, but I can't understand it for you. 

CP: CP's Pill Pauper Paradise. How may I help you? 

There Was A Time This Was A Thing: Can you give me a price? 

CP: $42.00

TWATTWAT: Huh? 

CP: You asked if I could give you a price. I did. $42.00 is "A" price. 

TWATTWAT: No. For my medication. 

CP: It could be $42.00. 

TWATTWAT: And it could not. 

CP: But it could be. Do you have insurance?

TWATTWAT: Yes. 

CP: Do you have the card? 

TWATTWAT: I used to use you guys. 

CP: And I used to sell drugs. I still do, but I used to too. 

TWATTWAT: I should be in your system. 

CP: Yes. I see a profile from 4 years ago. Has your insurance changed? 

TWATTWAT: Yes. 

CP: Ok. I'll ask again. Do you have the new information? A card perhaps? 

TWATTWAT: No. 

CP: Then I cannot give you a price. 

TWATTWAT: Why not? 

CP: I need the insurance to know whom to bill or at least to whom I should submit an online inquiry for a price. Since you will not, or cannot, provide this information, I cannot provide a price. I'm going to throw this out there as I'm sure you've already considered it, but you could call your insurance. 

TWATTWAT: This is ridiculous! I just need a price. I'm staying at my current pharmacy. 

CP: Probably best for all of us. And I still say it's $42. 

The Retail Phlu Phallacy

ME and MICE ELF: Are we going to be participating in this discussion or is this a solo diatribe?

CP: Solo diatribe. Try to keep up.

Flu shots are here. While the CDC generally recommends administering vaccines "as soon as they are available", they have not been anticipating the earlier-than-usual arrival of flu vaccines into retail pharmacies. We used to expect them around the last week of August/beginning of September. Now that we are receiving them the last week of July, perhaps we should press pause and wait until September to start vaccinating.

ME and MICE ELF: But you teach the class and recommend "as soon as available" and that the effects last.

CP: I do. I have also been administering shots for 15 years, and teaching classes for near as long. I have witnessed the change from "we are providing a valuable service to our patients" to "if you don't meet your goals, you don't care about your customers". Let me care about my patients and you worry about the other stuff. No matter what I do, my focus will always be on the safety and well-being of my patients. I ask for tech help and pharmacist overlap to care for my patients and you deny it. Yet you want me to vaccinate everyone in my county before Labor Day on top of ensuring I fill their prescriptions safely; on top of counseling them about vaccinations they need. I was doing a great job of this before you decided to force the issue (because of that $25.00 PROFIT YOU make on each flu shot; never mind the administration fee you collect on shots I give).

Personally, and through this page, I heard DM's quoted as saying: "if you miss your goal, you should feel bad because that's a person you failed to care about. you must not care about your patients if you let those shots walk out the door".

When we sold our souls to the Devil known as Corporate Retail, there was an implicit contract to which we all agreed: We, the pharmacists, would exchange our freedom, any ownership rights, and essentially money, for you, the Corporate Overlords, to handle insurance contracts, advertising, promotion, and the general running of the business side of pharmacy. Let's just say that I am doing a better job of caring for my patients than you are at running the business side.

If you really, truly cared about MY patients, as I do, then you would give me what I need to help them.

I need tech help.

I need pharmacist overlap.

I need time to counsel my patients about their medications.

I need time to discuss the needs for vaccinations with each patient.

Look, everyone knows every pharmacy offers vaccinations. I used to joke that patients would not simply stop by on their way home after seeing a sign and say "hey, hon. they're giving flu shots. let's get one while we're thinking about it", but I have seen this come to fruition in less than a decade. Much like getting gas, they pull into whichever corner is easier to get into/out of on the drive home.

How sadistic and unrealistic can you be to make someone's goal 8,000 flu shots when the population of the town and the total number of unique patients to that store is below that? Especially when the store administered fewer than 2,000 flu shots last year! Oh, you have such lofty expectations for the business but you did not increase tech help demand more than 20 hours per week. Nice. Not sure where I'll spend all that ~3hrs/day. Do I plan for a morning rush? A lunch rush? An after work rush?

ME and MICE ELF: In summary?

CP: I love administering vaccinations. I DO believe we are best-positioned to find these patients and administer vaccines to them. I have finally reached the point that no matter what any employer says, I am not going to try to reach my goals. I am going to continue to care for my patients, ALL OF THEM, not just the ones being pestered for shots, and make sure each patient receives the same amount of care. Now the CDC is recommending patients wait until September and that everyone should receive one by Halloween. Why should we have daily/weekly goals if the new CDC recommendation is to wait? And to every corporate shill who tells ANY pharmacy employee "a missed flu shot/vaccine is a missed opportunity to help/care for your patients" you can take these needles and shove them up your ass. (uncapped, of course.)

ME and MICE ELF: Basically, you can't tell the public you care about their health while forcing goals on employees and not providing them the help and safe practices necessary to protect the public. 

CP: Both from disease and their pharmacies. 

Reach your goals.

Don't reach your goals. 

But don't compromise your integrity simply because your bosses are trying to make you feel guilty for not giving that last patient a shot they had no interest in receiving. Remember, only ~45% of the country receives a flu shot annually. That means you can expect to get rejected more than half the time.

How Not To Be Seen

ME: What's the greater infraction? People who drop their keys on the counter or the coughers?

MICE ELF:  Coughers. You didn't have it when you entered, and you're not DJ Kool. 

CP: Let me clear my throat!

ME: Next one - People who stand between drop off/ pick up/ or consultation windows like lost puppies looking for a good home? or people who stand next to a line and get mad because you keep skipping them? 

MICE ELF: Lost puppies, especially with the COVID/ social distancing tape on the floors. 

CP: Here's a better one. Why do patients always stand behind the one pole/support beam for our gates in the pharmacy? 

ME: Then get mad when you don't notice them. You pick up your head, thinking you heard someone but there is no visual evidence confirming your suspicions. 

MICE ELF: Like truckers; if you can't see my mirrors, I can't see you. 

CP: Exactly. If you can't see me, and cannot make eye contact with me, I cannot see you. Just because you're used to working the pole doesn't mean your affinity for them is warranted in my pharmacy. 

ME: Especially when they are going to get mad they had to wait so long. 

MICE ELF: Perhaps they're used to bigger tips. 

CP: Or they're trying to hide in plain sight. Like little kids. . . or they're practising their championship hide-and-seek skills. 

ME: Perhaps they are shy and don't want to be seen?
MICE ELF: You mean they made it all the way down here, extricated themselves from their vehicles, only to plant themselves behind the nearest pole at my pharmacy? 

CP: Maybe they think we are going to snipe them with our blow dart flu shots. 

ME: Duck season!

MICE ELF: Rabbit season!

CP: They also hide behind the window frame. 

ME: What's worse is when they try to speak to us through it. 

MICE ELF: Glass is a great medium for voice conduction. 

CP: But the pole. I still don't understand the whole pole hide-behind. 

ME: They want to complain no one waited on them. 

MICE ELF: Maybe they don't want to be known at the "key dropper'' or the "cougher".

CP: Well, they're going to forever be known as either Mrs. Nesbitt or BJ Smegma going forward.

Clearly Canceled

CP: CP's Playhouse. How may I help you?  

Miserable And Demanding Doctor Of Grumbling 2020: I am calling about my patient's Rx which she claims is not there but I clearly sent last night. 

CP: I was here last night and have no recall of her prescription. 

MADDOG2020: I sent it at 7:29 last night. 

CP: Well that is of no help. Perhaps, if you use eClinicalWorks as your software provider. . . 

MADDOG2020:I just sent it again. 

CP: Ok. Let me check. . . 

MADDOG2020: <clearly grandstanding and frustrated> You should have it now.

CP: I do see it. Let me look at it. . . Aha!

MADDOG2020: It's the same thing I sent last night. I don't know why you told her. . . 

CP: I DO remember this one! I even had both my techs look at it before I canceled and deleted it. 

MADDOG2020:Why would you do that!?

CP: Read the directions. 

MADDOG2020:<mumbles>

CP: Out loud. So those in the back can hear.

MADDOG2020:  "oral caps cancel this fill tid"

CP: Yep. It clearly said to cancel it, so I did. 

MADDOG2020: Oh, I just resent what my NP sent the last time. 

CP: Good strategy, Silly Boy. And I'm guessing we followed those directions and canceled her previous refills the last time, when this note was relevant. 

MADDOG2020:Well that's not what I wanted. 

CP: Yeah, that's why we encourage you to review what you send before you hit 'send'. It's also why I don't allow verbal corrections on e-scripts from anyone in your, or any prescribers' offices. If it's not fixed on your end, it will continually be automatically renewed the wrong way and may, eventually, be filled that way which could harm a patient. 

MADDOG2020: Looks like I'll have to retrain her. 

CP: May want to be "starting with the man in the mirror". 

MADDOG2020: <humbled> I'll talk to her next week. 

CP: "I'm asking him to change his ways."

MADDOG2020: Good-bye. 

CP: "Yeah, make that change!"

<click>

Don't Think Too Hard

CP: Since we constantly have this debate, and we like to involve our students to teach them how to think, we are going to play a game.
CPP: The Professional Judgement Game?
CP Yes.
CPP: My favourite! Is this because everyone likes to comment on your posts about how we should just call? Or how they wouldn't ever call? Or how a counsel with the patient would have cleared things? Or how a consul wouldn't have provided an answer?
CP: Like those cure-all natural oil remedies - essential-ly.
CPP: Nice. Let's see this test.

1. Amoxicillin 500mg - Take 1 tablet by mouth 3 times a day.
(Do we dispense tablets or capsules? Or does it matter on this particular Rx?)

2. Amoxicillin 500mg Tablets - Take 1 capsule by mouth 3 times a day.
(Do we dispense tablets or capsules? Or does it matter?)

3. Duloxetine 60mg Tablets - Take 1 capsule by mouth 2 times a day.
(How do you dispense this one? If you said tablets for either of the above based on the drug written, then you have to answer tablets here and you have to call the prescriber, right?)

4. Motrin 800mg Capsules - Take 1 tablet by mouth every 8 hours.
(Tablets? Capsules? Call prescriber? If you answered tablets to any of the previous 3, then this has to be tablets, rights? Or is it Capsules because it's in the name?)

5. Insulin Glargine
(Do you dispense Lantus or Basaglar? If you try Lantus and it requires a prior authorisation, can you just switch it?)

6. Levothyroxine Capsules - Take 1 tablet by mouth once a day."

(But the patient ALWAYS gets tablets. Med selection error? or did the prescriber want Caps?)

Answers:
1. It doesn't matter. Just because "tablets" is written in the directions does NOT mean the prescriber intended for tablets to be dispensed. Often it's a default sig. Or pre-printed. Either way, it does not matter.

2. Meh. Same answer. It does not matter. Maybe his drop down menu only had tablets; or it was listed first. Same with the directions. As long as the patient gets 500mg of Amoxicillin, it doesn't matter. But if you claim that #1 HAS TO BE tablets based solely on the sig, then you must abide by your rule and dispense capsules here. Otherwise, your "steadfast" rules conflict and have no basis in real e-prescribing/dispensing.

3. Capsules. It's the only way the product is available. This is to prove that just because the directions use one dose form and the drug name is selected as another, albeit unavailable dose form, does not mean we have to move heaven and earth and call the prescriber to fix this. . . unless of course you disagree with either of the first two answers. In that case, stop wasting time. You know you just dispense capsules, so use that logic on #1 and #2.

4. Tablets. Period. Even though I have seen this very same prescription multiple times, there is no way the prescriber(s) intended to give the patient 800mg ibuprofen capsules. Tablets all the way. Again, if you disagree with any of the previous answers, then you MUST call this prescriber and verify capsules was correct as submitted. Another waste of time.

5. Please tell me no one does this. If a patient asks for ibuprofen OTC you can give them Advil or Motrin. Same here. If Lantus is not covered, try the Basaglar. It's written for the generic name, NOT the brand. Had the Rx been sent over as "Lantus Solostar", then you'd have to call, per insurance pain-in-the-assitude. I hate floating to stores and my first doctor calls are about these exact scripts; fix it.

6. Patient gets tablets. Give tablets. New prescription and the patient never had any Levo previously? It doesn't matter. But be a good Pharmacist and, if you try the capsules (Tirosint) and they are ridiculously expensive, simply change it to the tablets and save them money. We'd rather they be compliant and take their medication than quibble over whether or not the prescriber chose the first option from the drop-down menu (which she did).

Every pharmacist has her own quirks and panty-bunching idiosyncrasies. Don't put your brain out to pasture by forgetting why you went to school: to learn HOW to think, not what.

CPP: Think everyone passed?
CP: Most likely. We have a great group of phollowers. I think we will catch shit from people justifying why they call (insurances and audits and on and on) but I stand by our answers. Even if I get audited on 1000 Amoxicillin Rx's over 5 years, I'm only out like $42.00.

It's So Obvious It's Confusing

UT: How difficult are the terms "drop off" and pick up" to comprehend?

CP: Generally they are self-explanatory. If you polled random people around the world 84% of them would be able to correctly identify which one meant drop off and which once meant pick up. Unless. . . UT: Unless you polled patrons of retail outlets.

CP: Well of course then. It goes without saying that the retail world operates in a Bermuda Triangle-like set of parameters. Nothing is ever as it seems.

UT: <Sees patient at pick up window with prescriptions in hand> Do you want to handle this one?

CP: Certainly.

<CP pops up from behind computer like a prairie dog>

CP: Hello. Are you dropping off today?

Misses Out On Signs Explaining Key Nuances Usually Comprehensively Known Leading Everywhere: No. I am picking up.

CP: Hence your reason for being under the sign clearly marked as "Pick Up Here".

MOOSE KNUCKLE: Correct.

CP: <searches computer for MOOSE KNUCKLE. . . > I have nothing ready for you.

MOOSE KNUCKLE: She said she sent it.

CP: Who is this mysterious "she" of whom you speak?

MOOSE KNUCKLE: My prescriber. I just left her office and she said she sent it.

CP: Did she say she "sent it"? or that she "sent you away with it"? as in "sent it with you"?

MOOSE KNUCKLE: Huh?

CP: What's that in your hand?

MOOSE KNUCKLE:I don't know.

CP: May I see it?
MOOSE KNUCKLE: <hands over papers in hand>

CP: As I suspected. This would be your prescription.
MOOSE KNUCKLE: Right. I need to pick it up.

CP: Right. After you drop it off.
MOOSE KNUCKLE: She said she sent it.

CP: She did. She sent it to me via your hand. You are the delivery person of your own prescription. You can't just walk into Five Guys Burgers, head to the pick up window, and grab the first order number you hear them shout. You need to place your order first.
MOOSE KNUCKLE: But I thought it was placed.

CP: No. Your mates wrote down the order for you to take to the counter and place it yourself. Had you used doordash, someone else would be here picking up your order, not you.

MOOSE KNUCKLE: Ok. So what do I do now?

CP: Now that I have your prescription, you may sit until I call you. Then you may return to the Pick Up window as I now know you are quite familiar with its location.

MOOSE KNUCKLE: Why did she say she sent it?

CP: As I am not her, and since you have to wait, why don't you use this time to call her and ask her? UT and I are both dying to know.

MOOSE KNUCKLE: I don't want to bother her; she's busy.

CP: Right. Yet here I am, doing my job, herding people into the correct locations at my counters because they don't understand words while answering questions that should be posed to other people. Nope, not busy here.