Calling an Insurance Company

For anyone who has ever worked in a pharmacy and had to deal with insurance claims and issues they know how frustrating it can be. Many times insurance doesn't do what you want it to do, and you end up not only frustrating the customer, but being angry with the fact that something has gone wrong along the line of processing.
Some of the general insurance issues that I run into on a regular basis include the following:

• Missing or Invalid Patient ID/Processor Control Number/Group ID
• Missing or Invalid Patient Age or Gender
• this is usually a flub by the insurance company because most times the patient is there letting you know their birthday and the gender of their children
• Missing or Invalid Patient Person Code 
• 01-Cardholder 02-Spouse 03-Child 
• Prior Authorization required
• Doctor and Insurance company must come to an agreement 
• Missing or Invalid Day Supply 
• this is often an easy fix, if the prescription was written for a 90 day supply and the patients insurance company-usually Medco, only lets the patient receive a 30 day supply at a time, you simply change the dispensed quantity to that within a 30 day range of time
• Sometimes if a patient has switched or increased their dosage and we have not yet received the prescription from the doctors office-we will need to call and let the insurance company know that there has been a change in dosage 
• If the patient does mail order and they haven't received their mail order drugs yet and need some to get by 
• Override Codes Needed
• Diagnosis Code
• this may be a company code or a specific insurance code
• generally when a code has been used the pharmacy intern, tech, or pharmacist will put a note in the patient profile so that the next person who tries to submit a claim for them doesn't have to go through the hassle of calling the insurance company 
• Vacation Override Code
• when people are going on vaccation and need an advance on their medications ahead of time
• Transplantation Codes
• liver, kidney, etc transplants need a certain code for insurance companies to pay for their medications which are often extremely pricey 
• Company Codes
• For Hy-Vee by putting a 999999 you can often override rejections that the system sees as inappropriate 
• these could include DT: duplicate therapy DD: drug dose or others as well 
• Vaccination Codes

There are many other codes that could qualify for these as well.

When one gets a rejection, they generally try to do all the different "Tricks" that they can think of to try and fix the problem without calling the insurance company, but this doesn't always hold true. Many times the insurance company needs to be called which can be a heinous task.

Here is how many phone calls to the insurance companies go:
"Hello and thank you for calling Express Scripts (or other insurance company)"
If you're calling in regards to a refill request press 1, if you're calling for a rejected claims press 2 etc etc  and many times instead of having you press a number they will have you say "refill" or "claims" this is often erroneous in itself because many times the robot on the other end can't decide what you're saying.

It will then ask you the RX or prescription number that you're requesting to receive information about, and thereafter it will ask you other information such as your NPI number, phone number, and name. Then hopefully after this you will be able to speak to an actual person about your claim that you have questions on.

When you get to talk to a person you then will be asked the questions over again and then asked what your problem is. Many times the person on the other end will either have you go about adding codes or changing things until you get a paid claim, or they'll change the information from the main server and then have you try to re-process the claim yourself. Other times this is not so easy and they will have you require a Prior Authorization from the doctor for the doctor to contact the insurance company.

Many times the insurance companies want the patient to call them with questions about their medications, but if I was a patient who had never dealt with any issues in the pharmacy before I would be dumbfounded as to how to answer the questions that the insurance company asks. For this reason the pharmacy staff needs to be well educated on issues and insurance information.

DEA forms 222

Many pharmacy technicians when they first start to work in a pharmacy, along with pharmacy workers or anyone who hasn't been around a pharmacy setting in their life before are new to the idea of what CII is and that there are many different restrictions to what you can and cannot do with these drugs. Besides the fact that these prescriptions cannot contain refills, must have the name, birthday, and address of the patient listed on them along with other information, they also have very strict ordering and receiving policies. When I first started at the pharmacy we had a certain person who was able to the CII orders, but one of the times that it got messed up, they restricted the ordering to the pharmacists at our pharmacy. At the new pharmacy I work at the pharmacist is the only one who orders CII's.

To do so requires what is referred to as a DEA 222 form, and it looks somewhat like the above posted. The DEA 222 form has three different parts, the top part which you can see here, and two carbon copies for filing and keeping for a certain amount of years.

Here is some of the pertinent information that one should know regarding a DEA 222 form:
1) first and probably one of the most important, is that you can't "erase" or "cross out" mistakes, if you make a mistake you must cross through the document and keep it on file as a mistake record. Because if there is a problem on the order the manufactures then regard this is worthless.
2) These voided or unused forms must all be documented and tracked, along with the used and filled out forms as well
3) If one should lose a DEA 222 form or multiple DEA 222 forms, they have to report this to the DEA office as soon as they realize it.
4) Copy 1 and 2 are sent off to the manufacturer in a certain envelope that is provided and the last one is kept for the pharmacy's personal records.


When a CII order is received the following needs to be done as soon as the order is received if possible:

Required Information for Purchasing Records (DEA website)

The following must be recorded or appear on the invoice when acquiring controlled substances:

• Name, address, and DEA registration number of supplier or manufacturer from where this is from
• Name, concentration, dosage form, and quantity of controlled substance
• Signature or initials of authorized user receiving the shipment or pickup
• Date received

At our pharmacy this is all done by the pharmacist and kept in a certain CII booklet that is always checked before the end of the night. 

This is only a small insight into what it is like to deal with DEA 222 forms but even by this we can tell that it is something that you have to take seriously and know what you're doing before you proceed to do so. Many pharmacies have different methods of how they do this and their check methods, but either way this is something that needs to be done by a trained professional who knows what they're doing and how to do it. 

Pulling Outdates

Medications are given an expiration date and lot number by the manufacturer. The expiration dates are determined by the pharmacokinetic properties given to the drugs and are extremely important. Many people are under the impression that even though their medication is past the expiration date, especially with OTC products, that they can still use these medications. With some medications this is true, the only problem is that the potency of the drug will be lessened, however with some other drugs they may lose almost all of their effect after they've become expired. Because of this fact it is very important that pharmacy technicians and pharmacists make sure to pull out dated drugs regularly. There are many different ways to go about doing this in a community pharmacy.

One of the main ways to make sure that the expired or outdated drugs have been pulled from the shelves and not been dispensed is to first have a clear and organized system, and way of doing things. The way that we do it where I work, is when we do inventory, or count all of our drugs we make sure to check the expiration dates on the products. We then sticker the ones that are going to become out-dated in the next several months. This then will be put on a sheet and they will be pulled on the first of every month. Once pulled they're set aside to then later either be shipped back to the company and hopefully there can be money reimbursement for the product, either that or the store will just take a loss.

To make sure that drugs that are going to become expired within the next several months don't go to waste, there are different ways that pharmacists can try to get rid of the medication before it expires. Between the different pharmacies there is a vast network of communication  and many pharmacists send out email requests and ask questions about different medications, for example one such email could look like the following:

"Looking for Clonidine 0.1mg #60 if anyone is looking to sell"

Hy-Vee #28942

Once this message is sent out many other pharmacies can check their inventory and see if they have any they need to get rid of, and often times this is how many people can get rid of their soon to expire drugs as well, by asking others if they need any of the medication. It's a great system and can help save resources and money, so it is very important to always know the expiration dates on your inventory.

Pharmacy School Curriculum: Pharmacokinetics and Biopharmaceutics

As a second year pharmacy student going through the regular classes that all students need to obtain their pharm D degree, I find it extremely hard to gain any benefit from the following classes:

• Pharmaceutics: Solids and Semi-Solids
• Pharmcokinetics and Biopharmaceutic

I have completed the first class, and am almost finished with the second class, and unfortunately will have another pharmacokinetics class next semester as well. What I can honestly say that I have learned from these classes-and not for a matter of not trying-is that I understand "like dissolves like" and that there is such a thing as First Pass Metabolism. Other than these two fundamental concepts, there is not much more I understand or have learned from this class. The way this class is taught at the University of Iowa at least, is not benefiting me as a future pharmacist, or helping me do well in other classes. The main classes that matter I'm doing fine in, but this class which many pharmacists now will tell you is completely pointless, I struggle. It's not a matter of me not studying, or the professors being completely terrible, but the subject matter is something that I believe one should not have to be tested over. 

One of the first things that they tell you in these classes is "there is no black and white" everything is very variable and dependent on individual patients. So how are we supposed to be tested on something when we have to take into consideration the certain circumstances of our clients? The way that my first exam for this class was structured was I was handed a 50 page handout of package inserts and drug product information along with the actual 18 page exam itself. I was then asked questions such as "What are the purpose of the following excipients in this product?" It angered me because the questions on the exam were questions that when pharmacist get ask-which I doubt is frequent-they learned the drug information resources their P1 year and can confidently search for this information in a quick and easy manner. I can't justify learning and memorizing different types of excipients when they're doing something different in every product. Nor do I believe that it is important to know the exact size of alveolar sacs and how fast a nasal spray is going to travel into the back of the throat. Along with this the fact that we received 50 pages to read for 5 point quizzes over anatomy questions to better our learning didn't do anything but hurt my grade, regardless of how well I studied. 

My main frustration comes with the fact that I go to class, I take good notes, and I try to learn the concepts but they're so old age and not taught in a way that we as students can understand that it makes studying a complete misplay. I have been taught what hepatic clearance, volume of distribution, and area under the curve are time upon time, and yet if you asked me to tell you a definition of them, I couldn't. It's information that is being taught to us in a way that doesn't seem at all important, the teachers themselves even act like they don't want to be there, so how can they expect their students to enjoy what they're learning? It's bad enough hearing other professors at the college say that they as well don't think that they class has any purpose and what they're asking us is ridiculous. I feel that had I gained a better understanding of the basic concepts of what this class is trying to teach us I would be doing a better job in the class, but I even went into office hours last year to try and gain the basic concepts and came out with nothing. So in my opinion as far as testing for this class, I think it is a complete waste of time and that the students are gaining nothing from it. 

How to build and maintain trusted relationships between pharmacist and patient

Building a relationship based on trust is one of the most important aspects of the pharmacists job description, because if it wasn't for the patients, pharmacists would be out of a job in the first place. From working in a pharmacy the last five years I have been exposed to working with six different pharmacist, each one very unique and different from the others, and yet they all have one thing in common: genuine interest in the care of the patient. Working with people’s medications is a very serious job and it is one that requires the pharmacists full attention and effort, and to do so the pharmacist has to be sincerely passionate about what it is they are doing for the patient. By caring about their patients health the pharmacist should be expected to take their time and make sure that they get to know every patient and try to remember something about them so that the patient knows they were listening. Letting the patient know that you are listening to what they have to say—whether it is right or wrong—is a key point to building their trust because it shows them that you do care what they have to say, and it lets them know that you are there for them. When a patient comes in with a question the pharmacist should take time out of what they are doing, no matter how busy they are, to attend to every patient. By doing so they show the patient that they are their number one priority and that they will make time to help them the best way that they can.

            Making the patient feel comfortable is another way that the pharmacist can build the trust of the patient. Many people come in with different questions, some that are often rather difficult to answer, or out of the ordinary, so the pharmacist must be outgoing and not afraid to answer the patients question. Pharmacists must be very open to sharing their feelings with the patients and showing their concerns for the patients as well. The patients that I have worked with over the years always enjoy their trips to the pharmacy because it takes the edge off of things when the pharmacists that you work with are not only viewed as your health care providers but as your friends. After working on a team of 6 pharmacists you stop feeling like employers who are helping patients and start feeling like a family who is helping to aid their friends. The atmosphere in the pharmacy setting can be one full of trust if the pharmacist and the patients are willing to work together.

            To be able to work together and have constant flow between the pharmacist and the patient the patient has to allow the pharmacist to get personal with them all the while maintaining the practice of professionalism. By getting to know these people and letting them know you remember them, taking care of each and every one of their individual needs shows them that you put their care above all else, and that is what is going to create the bond between the pharmacist and the patient. Even in high velocity pharmacies that fill over 900 prescriptions a day it is still very important that you get to know all of your patients, by taking an extra minute to see how they’re doing and taking the burden of the day off their shoulders, because usually the people that are coming into the pharmacy aren’t there for a good reason so being able to make their days even a little bit better should be one of the pharmacists key ways of building a relationship with them.

• Listening to what the patient has to say no matter the situation
• Giving the patient the benefit of the doubt and trusting what they have to say
• Never making the patient feel inferior
• Explaining things to different types of patients at their level
• Being not only pharmacist friendly but genuinely friendly, creating a bond between pharmacist and patient that is not only work and health related but socially related.

o             Working at the pharmacy the pharmacists that I work with are some of the most well respected people in our community and they are always having people stop into the pharmacy even if they don’t need medications but just to visit with our pharmacists

• Getting to know the patients by name and face, not just by what medications they’re taking
• Remember key details about their lives that are important to them and that you can talk about with them the next time they come into the pharmacy
• Always treating them with the utmost respect because you don’t know what they may be going through at the time and so even if they are treating you in a rude manner just always being the nicest that you can be

·                                 Helping them to understand everything about their medications and making sure that they trust your decision making skills by showing them that you know what you’re talking about and that you are keeping them in your best interest

·                                 Making them smile and laugh, keeping the relationship light hearted and not only about them getting their prescriptions

·                                 Making sure that if they wish you talk in confidence that you let them, showing them that you do care about their trust and keeping their information private because many people have different issues that they are in there for that they do not want shared with others

·                                 Overall, building a friendship yet still working still reinforcing the professionalism of the client pharmacist relationship 

Pharmacy Delivery Systems

One of the major complications for the elderly in being compliant with their medications is the fact that many of them cannot drive to the pharmacy to actually receive their medications in the first place. Especially during the winter months when they're concerned with driving in general, they sometimes will just decide that they would rather not take their medications because they don't want to drive. Many elderly patients have family members who can stop by the pharmacy for them and deliver their medications, but many do not. For those that who don't have anyone to come get their medications, or who have had their license taken away, they often feel hopeless like they don't have a way to take their medications, when this is not the case.

Many pharmacies are implementing systems that allow medications to be taken to patients-whether they're patients with disabilities or just patients who would rather have their medications delivered to them. Depending on the prescription volume of the pharmacy the pharmacy will either hire a delivery service to come to their pharmacy and deliver the medications to the patients, or one of the technicians will take their medications to them. At our pharmacy we have one of the technicians deliver medications to not only different nursing home style facilities, elderly patients at their apartments, but also to ACT, the testing station. Many of the patients at ACT have busy schedules and so our pharmacy has came up with a system to deliver their medications to them. All of the patients from ACT have charge cards that they have kept on file with us, and every week we go through the books and on either Tuesday or Thursday we deliver to these patients. Along with charging these medications to their cards, we have to make sure that we remove all of their patient information from the outside of the packages so that we don't violate HIPAA. Along with this we have to have a general signature slide that the main boss at ACT signs allowing their medications to be distributed.

When we deliver to different places such as WestBranch facilities, we have to ring a buzzer to be let into the home, and then the nurses either take the medications from us, or we take their medications to their room. So this way many elderly patients are taking their medications and not skipping doses, increasing compliance and decreasing their chance for having polypharmacy and increased adverse reactions and unwanted side effects. The problem is, many of these patients are unaware that having their medications delivered to them is even an option. Pharmacies need to make sure that they are advertising their delivery services sot hat these patients don't think that they are hopeless, this will not only help the patients but help the service of the pharmacy.

ABN forms

This past week a fragile elderly lady came into the pharmacy with a prescription for a front-wheeled walker, assuming that if she handed us the prescription we would just run the prescription through the computer like all her other medications and have her on her way in less than ten minutes. With durable medical equipment, better referred to in the pharmacy world as DME the process is not so simple. There is a plethora of different forms that need filled out, along with proof of insurance, on top of about 500 signatures that are required from the patient, and even after all this is done, it isn't guaranteed that the patients DME that they're getting will be covered. So why do these patients have to go through the hassle of filing for paperwork anyway? Medicare requires that these patients fill out this paperwork before they can receive their DME supplies. These patients are then required to fill out what is known as an ABN form. An ABN form stands for Advance Beneficiary Notice and the actual form can be found here :

http://www.dbhds.virginia.gov/documents/manuals/OCAR-CommunityReimbursementAppendixA.pdf

This is one example of a form that is commonly seen in community pharmacy practice. What is required is the reason that they are getting the prescription, along with the estimated cost of the product in case medicare decides not to cover the product, the name and information of the patient, along with their diagnosis. There is then a section for the patient to say that yes they want to receive the product or no they do not. There is also in the yes section an option that says if medicare does not cover these products they know that they are to pay the wholesaler price that was quoted to them when they picked up the product. These patients will get to take the product with them that day, and then they will receive a letter in the mail within a couple weeks from medicare letting them know whether or not they were eligible for coverage; the pharmacy also receives this product so that they can not only keep it for their records but that they can make sure that if it is not covered they get paid for their item.

Other items that are considered DME can be anything from Breast Pumps, Nebulizers, Crutches, Diabetic shoes, canes, raised toilet seats and others.

These patients will then have a folder that is kept at the pharmacy for proof of their purchase in case medicare were to audit them and ask for this information. Medicare limits coverage of certain items and services by the diagnosis. If the diagnosis on the claim is not one that Medicare covers for the item or service, Medicare will deny the claim. Many patients will be upset knowing this but it's under the control of Medicare and Medicaid services and not the pharmacy, but make sure that you are very empathetic when working with these patients, because finding out that medicare isn't going to cover something that they see as essential can be a tough time. Also from the pharmacy stand point when they are entering the prescription into the computer they need to make sure that they are using the diagnosis codes that they were given, or else medicare will not recognize the claim and reject it. So knowing all of this it is very important that not only the pharmacists but the technicians are aware of what all goes into working with these ABN forms and how they need to be  dealt with to make the experience the best they can for the patient.

More detailed information can be found at the following location:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf