Medicare: None of Us Is As Dumb As All of Us

An Open Letter to the U.S. Department of Health and Human Services, the Centers for Medicaid and Medicare Services, all 86 Medicare part D plans in the state of Arkansas:

(or why I don’t drink, smoke or do drugs but still will die before 50)

Dear Fhqwghads:

Part of me wants to believe that government inherently wants to help people. Then I see the actual way it works and it makes me ill.

I thought today that perhaps if you could get a glimpse inside the world of average America pharmacies, a fly on the wall if you will, you might change the approach you’ve taken in solving all of our prescription medication needs. I offer this glimpse into an afternoon to show you just how hard you’re making it for business to make money and for patients to get their medications. I’ve included dollar amount tallies as well as time expired to give you an idea of what we have to go through just to earn a dollar.

This afternoon at the home infusion pharmacy where I work as a pharmacist, it all started with a call from a physician…let us call him Physician X.

For calculation purposes, I used the average salary of a pharmacist in Arkansas along with the average technician salary to calculate the waste involved.

Pharmacist avg for Arkansas: $93,555/year

Let’s call the Technician avg.: $9.00/hour

00:00 Call placed to pharmacy and transferred to me to take order. Nurse on the other end tells me that Patient Y needs an antibiotic IV for her urinary tract infection. She seems like this isn’t her first dog and pony show as she astutely observes that ‘Levaquin is probably not going to be paid for, so let’s give her Cipro 500mg twice daily.’ I concur.

04:04 I hang up with the Doctor’s office and pass the prescription off to our intake and billing checker who will carry it to the next step…Insurance verification.

04:58 The Pharmacy Tech calls the patients insurance company (luckily it was a previous patient that we had everything on file) to verify benefits. After a short 15 minute wait on hold, we are informed happily that “She is covered and only has a $1 co-pay!”

Isn’t Medicare Part D wonderful?...don’t answer yet.

19:58 The order is handed back to the Pharmacist (me) to calculate and compound. I deftly run the order in a speedy three minutes. After all, this isn’t MY first dog and pony show. After calculating the order and processing it on our $10,000 dollar software system, I prepare to on-line adjudicate. This is a process by which, with a push of a button we can find out instantly if we are going to get paid by the insurance company. It costs $0.09 cents every time we do this.

23:00 The claim gets sent back REJECTED. The message accompanying the rejection states “Rejected due to Missing/Invalid Physician ID Qualifier.”

Normally, that’s useless, but I’ve been down that road before. I quickly find the empty blank for the Insurance company in our software and fill it in. (Oh, and I counted the number of blanks to fill in for this rant. The total comes to 129 empty blanks to properly file the prescription online.)

Send it again. ($0.09) One sound of an electronic handshake later, REJECTED. View response. “Rejected due to invalid patient location code.”

Check blank for patient’s location code. It reads ‘Home’. This is correct. Contact software company to help untangle the maze that is 129 blanks, each with multiple possible entries.

28:00 All software technicians are currently busy. We will have to call you back. Please leave your name….etc.

58:00 Technician calls me back. He deftly dials into my computer from somewhere in Akron, Ohio and navigates everywhere I’ve already been. I can hear his supervisor whisper into his headset as if I cannot hear, “See if he’s checked the AWP!”

I answer before ‘Joel’ can. “I have. I also checked the NDC, DEA, U&C, MAC, and expiration dates!”

He finally discerns that if he holds his tongue just right and changes the ‘Pt location’ from ‘Home’ to ‘Not specified’. It might work.

Re-submit. ($0.09) REJECTED. View response. “Rejected due to missing/invalid NDC/U&C/AWP and/or expiration date.”

My head hits counter…repeatedly.

‘Joel’ re-checks all of the numbers I’ve already told him I checked, resubmitting it to test it each time. REJECTED. REJECTED. REJECTED. ($0.09)($0.09)($0.09)

89:07 Joel gives up. Insists the fault lies in the insurance companies setup. I thank Joel for his $10,000 help. Hang up and call Medicare Part D plan…again.

90:00 After cool 5 minutes of wait time, I pull of getting to talk to perhaps the WORST customer service representative of all time. Ebony. Our conversation went a little like this.

Ebony: Helloandthankyouforcalling(Plan Z), mynameisEbonyandmynumberis119876459s876whichyou’llneedtoregister

anycomplaintcanIhelpyou?

Me: (in summary, I tell her the problem)

Ebony: I need your NCPDP number please.

(Here’s where I go on the rant about the new Orwellian NCPDP numbers that every med provider has to have…then I give it to her.)

Ebony: We don’t have that number listed.

Me: (I explain to Ebony that we just spoke to someone at her company 90 minutes ago and verified that we were in network and that they had the number then.)

Ebony: Oh, here it is.

Me: The NDC# in question is xxxxx-xxxx-xx.

Ebony: (After a moment of ignorant silence) We don’t show that NDC number existing.

Me: (I explain to her that perhaps she needed to try it again. NDC numbers always have 11 digits and maybe she wasn’t typing in the preceding zeroes. (dog and pony)

Ebony: (as if I didn’t just correct her) Why are you sending this out for her?

Me: (I remind her through loud flagrant shouting and terms such as TELEPHONE JOCKEY that reasons for therapy were none of her concern and that it was an obvious HIPAA infraction to even be discussing it with her. I also reminded her that it was the insurance company’s job to help their customer, NOT to find ways to deny her coverage.

Here, Ebony puts me on hold.

Ironically, I get to listen to most of ‘Land of Confusion’ by Genesis before she comes back on the line.

Ebony: Okay, here’s a number you can put in the Prior Authorization field of your submittal invoice that will override the rejection. But, once used, you will not be able to dispute the charges.

Me: Whatever.

106:00 I hang up and resubmit. ($0.09) PAYABLE! I hear harps and see the paper hand come out of the clouds from Monty Python’s Holy Grail.

I examine it closer and this is what the breakdown was.

Claim status: Payable

Patient Pay Amount: $1.00

Ingredient Cost Paid: $0.29

Dispensing Fee Paid: $2.00

Flat Sales Tax Amount Paid: $0.00

Percentage Sales Tax Amount Paid:$0.00

Percentage Sales Tax Rate Paid: $0.00

Percentage Sales Tax Basis Paid: $0.00

Incentive Amount Paid: $0.00

Professional Service Fee Paid: $0.00

Other Payor Amount recognized: $0.00

Total Amount Paid: $1.29

Now let’s figure the cost it took me to earn that $1.29

Pharmacist salary: 91 minutes X $0.64/min=$58.24

Technicians salary: 15 minutes X $0.15/min=$2.25

On-line adjudication fees: $0.09 X 6 = $0.54

Drug costs: $1.74/vial X 3 vials = $5.22

Total cost to make and dispense: $66.25

Total net profit: $-64.96

Isn’t Medicare Part D wonderful?

This doesn’t include the cost of appealing the price paid on the prescription, which I’ve done. They told me they’d get back to me in 3 or 4 days.

How do they even get away with pricing it LESS than what I paid?

This whole Medicare Part D program is Bullshit.

Yours truly

Midnight Train

Stay tuned for my next Open Letter to Pharmacists everywhere entitled:

Solidarity NOW you Lech Walenza Mother F*****s