When Is My Job Finished?

CP: When are we actually done with our job?

ME: All of it? When the Rx is sold? 

MICE ELF: Once I sell it, our interaction is over. 

ME: Allowing for calls back with questions, etc. But I'm guessing that's not what you have in mind for us today? 

CP: Observant. It is not. I shall ask again, rewording this time. If you process a claim, and you are rewarded with a paid claim, is your job done?

ME: Of course. We bill the insurance as a courtesy to help finance the cost of the medication. 

MICE ELF: Yeah. Once the insurance replies with "yes, we accept the terms of our arrangement and hereby agree to pay our part (for now) as long as you charge the patient her $25.00 copay, our transaction can be considered concluded". 

CP: Verbosity. You definitely speak like an insurance company. But you are wrong.

ME and MICE ELF: WHAT?!

CP: Is there a cheaper manufacturer? A preferred NDC#? Just because you received a paid claim does not mean you get to celebrate yet.

ME: But that has always been the way. 

MICE ELF: Yeah. This is the way. 

CP: Alas, no longer. We have had multiple instances where we processed a claim, told the patient her copay and when she balked, instructed her to call the insurance. When she called us back, she bluntly explained we used the wrong manufacturer. 

ME: Wouldn't it make more sense for the insurance to simply deny the initial claim for "NDC not covered" than pay the claim at a higher copay? 

CP: One would think. But insurances are not in the business of making it easy for us or their patients. It's like finally getting the notification that the insurance company approved the provider's prior authorisation request, only to process the claim and discover there is a 90% copay for the patient now. Thanks for nothing. Now the patient is still mad at us because we are overcharging them. 

MICE ELF: And we continually get yelled at because we had a paid claim. How are we supposed to know which NDC is preferred? I miss the days when brand was no longer covered the day the generic entered the market. I miss all generic versions being covered by the insurance. 

CP: I miss the days when there were no insurances or PBMs and patients paid cash for everything. We need to move to the medical billing model. Patients pay an office copay before each visit. We accept their $25.00 copay up front and all of the billing takes place behind the scenes or after the fact. Pharmacies should have their own billing departments. 

ME: You are so wise.

CP: And don't get me started on "would it be cheaper with GoodRx or a discount card?". 

MICE ELF: It's not my job to figure out ways for me to lose money to you. 

ME: Could you imagine going to a business and telling them you don't like the price you are being charged and expecting THEM to help YOU pay for it? 

MICE ELF: Or to suggest a better, cheaper location. 

CP: You picked me. You don't have to come here, oh wait, damn PBMs. But once I get a paid claim, my work here is done. Transaction complete. Here's your receipt.