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Tuesday, September 1, 2020

Why Insurances Suck #245

CP: <hangs up phone, disturbed look on face> Huh. 
CPP: That sounded interesting and bad and confusing all at the same time. 
CP: <shakes head> It was. 
CPP: Care to share?
CP: Hoping you'll help me make sense of it. 
CPP: Role-play? 
CP: We have to. I'll be "Auditor Harassing With The Facts" and you be "ME". 
CPP: Okay. 

Auditor Harassing With The Facts: Hi. 
ME: Hi. 
AhWTF: I need you to reprocess a claim for me. 
ME: Ok. Was there a mistake? 
AhWTF: Not exactly. It's just the days supply was entered incorrectly. I need you to fix it before it gets filled again. You could lose the payment on this claim as well. 
ME: I see. <checks hard copy and how we filled it> What, exactly, was the problem? We filled and billed it correctly. 
AhWTF: Well, the directions state the patient is to use it 4 times a day. 
ME: . . . as needed. 
AhWTF: Yes. Four times a day, as needed. Since she was prescribed 60 tablets, that means that 60 divided by 4 is 15 so it should be a 15 days supply. 
ME: Right. I know how to do math and calculate days supplies so thanks for the lesson. My concern here is that the prescriber wrote, in the directions, that these 60 tablets "MUST LAST 30 DAYS", thereby making this a 30 days supply. 
AhWTF: No. It's a misfill due to the math. 
ME: If a prescriber writes for 1 tablet to last 30 days, then it's a 30 days supply. 
AhWTF: No it's not. 1/1=1. 
ME: Okay. What happens when this control gets reported to the State PDMP? The prescriber's intention for this to last 30 days isn't seen by anyone checking the report. It shows as a 15 days supply. This then thwarts the system, allowing for early (re)fills.
AhWTF: You either get paid for the claim with the correct days supply or you report it to them correctly. We don't care about anything other than the proper billing. 
ME: BUT IT WAS BILLED PROPERLY! The prescriber wanted it to last 30 days. 
AhWTF: You can put whatever you want in the directions; we don't care about that. 
ME: I'm pretty sure my State BOP will have a different opinion on this matter. 
AhWTF: Please change the days supply to ensure payment. 
ME: No. Proper billing is not part of my Oath of a Pharmacist, but taking care of my patients is. You can call my State BOP and explain this to them. If they acquiesce and change the law for you, then I will change it. Until then, off you may bugger!

CPP: How'd I do? 
CP: Bang on. I especially enjoyed "off buggering". 
CPP: I can't believe the insurance wanted you to make the days supply wrong.
CP: It would sound like insurance fraud if it weren't coming at the behest of the insurance. 
CPP: It's cases like this that remind me of your favourite John Grisham quote: "If it wasn't for lawyers, we wouldn't need lawyers". 
CP: If it weren't for insurances making things harder, we wouldn't need insurances?
CPP: Something like that. I wonder what the days supply for a Depo-Provera shot should be? 
CP: Good question. I wish I had thought to ask.

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