Just another Wednesday...
5pm or so... dinner rush. People picking up and dropping off. It's chaos. A lady calls and wants to know what tier her prescription processed under. I tell her, in a quick fashion, because I don't have time to chit chat, that we don't get that information when we adjudicate. It just tells us what to charge the patient and she will need to call her insurance to find out.
6pm or so... a call from someone at that lady's insurance company. She wants to know why the patient's co-pay is $235.12. Honestly, she asked me why that was the co-pay. She seemed befuddled, like someone new on the job or poorly trained. I explain to her that the co-pay price is set by the insurance company she's calling from, not Goofmart. She thanks me and hangs up.
6:30pm or so... the lady's husband now calls. He has attitude... a real bad attitude. He says he just spoke with the insurance lady mentioned above and wants to know WHY we're charging his wife $235.12 when the lady CLEARLY told her the co-pay would be $45 because it's a Tier 3 co-pay. Before I even begin to answer he tells me that if he's not satisfied with my answer that they will take their business elsewhere.
As calmly as I can, I try to explain what happens on our end. Before I'm even through with the first sentence he cuts me off and goes on for a paragraph about how he put the information for the drug on the website and how it said $45 and that the insurance lady was on the phone with him for a long time and assured him it was $45.
So after he finally shuts up, I start to tell him again about the adjudication process. I tell him when we send off a claim for payment, it goes through the web somewhere... then he cuts me off again and says, "I don't want to hear that crap. You're not giving me any details. I'm losing faith in your ability as a pharmacist..." and goes on again for another couple of sentences. So ok, I've got a real jerk on the line now and he wants details. So I start by telling him about the numbers we need to process a claim... BIN, PCN, group, Cardholder ID. He stops me. "Cardholder ID? What's that?" So I have to tell him that's his wife's ID number PRINTED on the insurance CARD. (Really) Then he wants to verify all this information with me, so I do. When I get to the group it's not what he has written down. "Ah ha! Ah ha! I knew you people had something wrong!" I ask him for the group again and change it in the computer. It's really the same group, just a different state, but he wouldn't believe me. Anyway, it comes back $235.12. I tell him.
He gets belligerent and tells me that there's something wrong with our system because he was told that the co-pay would be $45. I try to explain to him once again that WE don't set the price... it is SET BY the insurance company. I then tell him that the lady that called me seemed confused about the process herself... and she was. It was odd, I told him, because someone in the pharmacy benefits should know how it works but she didn't seem to know at all. I said the insurance lady seemed confused.
Now he has an even worse attitude. He tells me that I'm the one with the problem. "Me? You mean ME personally?" I asked. "Why?" I'm told because the lady that helped me was really nice and wasn't confused. He says I'm the one that's confused. He also said his wife was treated rudely yesterday by whoever helped her. From what he said all I can ascertain is that the same information I gave was given to her about the tier of the drug and the co-pay, and additionally was first told the price was over $1,000. He obviously didn't understand that whoever helped her was just telling her the cash price.
I apologize (for what reason, I have no idea why) to him and tell him I will call the insurance and find out why it is $235.12. He said "You better or I'm taking my business elsewhere." So then I tell him, "Let me verify YOUR phone number. I start rattling it off." And then he was ruder than ever before: "Ah ha! Ah ha! That's why I don't have any faith in you! That's MY number, not the number of the insurance company!"
I sigh. "I'm verifying YOUR number so I can call YOU back when I'm done calling the insurance."
I call the insurance, and of course, verify that the co-pay is $235.12. I explain the situation to "John" (with the east Indian accent) and tell him how angry the patient and her husband are. I tell him that they're expecting a co-pay of $45. "Yes, it is $45, but they have an upfront deductible of $190.12." When I ask why the patient wasn't told this by the insurance lady, I get "I don't know." I can't be mad at John. How would he know?
So... I call back the husband and explain the upfront deductible and that the co-pay is indeed $45 but that the deductible is collected with the co-pay. I couldn't help myself. I said "This is why I said the insurance lady you talked to seemed confused to me... this is information she should CLEARLY know and should have told you."
For the first time... silence... then "So the co-pay is $45 and there is a deductible that brings it to $235.12?"
We'll be down to get it tomorrow. <click>
No apology for being an ABSOLUTE ASS. Nothing.