Why should pharmacies notify physicians about rejections?
Friday, February 23, 2018
Will Rogers apparently once quipped, "I don't make jokes. I just watch the government and report the facts." Rogers would have a field day with some of the "facts" that are coming out lately.
Apparently, the Massachusetts Supreme Court is hearing arguments about whether pharmacies should be required to notify physician offices when a prescription is denied by the patient's health plan. While some pharmacies may do this as a best practice or courtesy, the legislation would apparently make it mandatory.
Unfortunately, there has been so little coverage of this story that limited information is available. In fact, all I could find was a short note by the American Pharmacist's Association that the Massachusetts court "is considering whether pharmacies have an obligation to inform physicians when health insurers refuse to pay for a patient's prescription without prior authorization."
I'm not a political writer. While I appreciate and respect the work done by our representatives for the common good, I'm often baffled by the absurdity of some of the things being debated. This is one of those times. The fact that this is a matter for discussion and that someone out there is actually arguing that pharmacies have such an obligation only confirms my skepticism about the political process.
Let me make my position clear. The only entity with an obligation to inform the provider is the PBM that is rejecting the claim.
They have refused to pay for it. They rejected the claim. They demand additional steps before allowing the patient access to the prescribed drug. They, therefore, should have to notify the M.D. Not the pharmacy.
Think about it this way. When a PBM restricts access to a medication, the pharmacy has already done a lot of work for which it is not getting paid.
We have added the patient to our computer. We have read and entered the prescription information (not always easy). We have checked their allergies. We have entered all their insurance information — a process that sometimes involves a lot of time because patients don't have their correct card.
The moment the claim is rejected, the pharmacy then has the job of explaining to the patient exactly why it cannot be filled. All of this takes time, and none of it is paid for by anyone.
The PBM should not only have to inform the physician, but also provide the physician office with a partially completed prior authorization form that clearly explains the criteria and what needs to be done for approval. Additionally, once approved, the PBM should be required to allow the original pharmacy to dispense the medication since they already put work into it for which they were not compensated.
This is common sense. The health plan rejects the claim for, among other things, financial reasons. Since they are looking to save money by rejecting the claim, the least they can do is notify the prescriber of their decision.
This would be easy for them to implement, but since it is not in their financial best interest, they refuse to do so. Rather, they put layers of barriers, complicated approval processes, long hold times on the phone and route callers to numerous departments all in an effort to make the approval process so laborious that it is abandoned. This isn't right.
From what I could find online, it looked like Walgreens was giving testimony on this issue, presumably arguing (as I have just done) that the obligation belongs to the health plan and not the pharmacy. But I'm sure the PBM industry has lobbyists prepared to argue that pharmacies have nothing better to do than to report their rejections to the respective doctors.
I feel bad for the patients. We and our techs typically bend over backward to try to help our patients get the care they need — fighting all day long with the insurance companies just to get them to cover treatment.
I'll say it again: I'm not a political writer. I do appreciate the hard work done by legislators that truly care for people and want to improve our healthcare system. But this issue makes no sense to me.
Don't force pharmacies to do one more thing they don't get paid for. It isn't good for patient care. Their lives are on the line. And that is nothing to joke about.
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