But That Would Be YOU!

CP: CP"s Nostrum Emporium. How may I help you?

Insurances Don't Ideate Obvious Things: I am trying to get my client her prescription. 

CP: Certainly. That is ideal because I too am in the business of helping my patients achieve their lofty goals of filling prescriptions. 

<whispers> Let's see who cares more. 

IDIOT:  What's that? 

CP: Nothing. Carry on. 

IDIOT: Her refill is too soon. Is there anything you can do for her?

CP: I can call the insurance company for an override but, um, aren't you the insurance?

IDIOT: Yes. We need to exhaust all avenues and determine if there is anything the pharmacy can do first. We'd have to call the plan itself for an override.

CP: Sure. I can tell you to allow the refill. Easy. She received a 30 days supply, as she has for the previous 3 years, and today is day 29. She is due. However, your reject is telling me she cannot receive it until 20 days from now. 

IDIOT: Well, she has been a couple days early each of the past few months. 

CP: Okay. So it's a "cumulative fill" reject, then? 

IDIOT: Yes. But she was in the hospital last night and really need this medication to monitor her disease state. 

CP: I know. She told me that. Which is why I would like to get her prescription in her hands. Can't you enter an override?

IDIOT: No. 

CP: Why Not?! You're the ones holding it up!

IDIOT: No. We are trying to make sure she has some. What can you do?

CP: No! No you're not trying to make sure she has some. YOU are the insurance. YOU are denying her refill, which is actually due, by 20 days. YOU are telling me I can't fill it. Yet YOU are also asking me to fix a problem you created, a problem only YOU can fix. 

IDIOT: Can you give her some?

CP: Can you pay me for them?

IDIOT: As we told the client, we are not denying this for a prior auth. It is a covered medication. 

CP: Yet you are not paying for her to test her blood sugar 5 times per day, as you have previously. You allowed 150 strips to be billed for 30 days, but you are making her test only 3 times per day. This necessitates a prior auth for frequency, NOT for the strips themselves. I can't believe I have to explain to YOU, the insurance company, how insurances work. 

IDIOT: Thank you for taking the time to politely explain to me how the system works. . . 

CP: Did it help get you to override the claim you are denying?

IDIOT: No. 

CP: Then your company is dumber than I thought. You have the power to deny the claim, which you did. You alone have the power to override and approve the claim. Until that happens, the patient's life is in your hands and I shall document your refusal. What was your name again?

IDIOT: That's not important right now. 

CP: At least you said this call is being recorded so I'll just track it down that way. 

UT: What's up? 

CP: Insurance is a big dumb.

UT: Let's see what I can do. <waves magic fingers over keyboard> Voila!

CP: Not going to ask. 

UT: Plausible deniability. But it's documented too. Called the prescriber and they are submitting a prior auth for the frequency. All good. 

CP: Can we do away with PBMs yet?