Before I say anything else, I have to make a big correction to my last post in which I talked about the changes since I started working. I omitted a very big, very important change that took place recently.
I forgot to mention how I am now involved in an amazing relationship with an amazing woman who absolutely completes my life.
The error is being corrected not because of pity, but because it was a huge one that should not have happened. My apologies to her.
Now then, back to the task at hand.
All of us who have worked in a pharmacy for any amount of time know that insurances often change things up at the beginning of the year, often throwing a huge wrench in things for the first month of the year as we try to figure who changed to what, what is and isn't covered anymore, and whether we want to reach through the phone to strangle the customer service rep, or just drive there instead to do the job.
To understand where the recent problems stem from, you have to understand a couple of things about my state's Medicaid system. Where I live, it's broken down into four different branches. There's Medicaid and 3 off-shoots, who up until 3 years ago, were processed by various insurance processors. One was processed by WHI, anothe by Express Scripts, and the third by US Scripts. 3 years ago, Medicaid decided to combine them all into one processor, thus creating the first set of issues we had, mostly with the Express Scripts one since that one let you get all kinds of OTC stuff that regular Medicaid didn't cover. For a few months, all we heard was people scream at us because their OTC ibuprofen was no longer covered because "MY INSURANCE COVERED IT BEFORE!"
Well after getting everyone used to that system and the formulary that Medicaid used, things were relatively fine.
Then about a few months ago, word started to spread that later in the year, Medicaid was going to split the three other versions off again. We didn't hear much else until my girlfriend received a newsletter telling her that her daughter's version was going to be processed under a new company and to be on the look-out for the new card (as of this writing, she still hadn't received and the changes took effect on the 1st).
It wasn't until right before the end of September that we started to see new cards. Much to my surprise, two of the three are back to their original processors, WHI and US Scripts. The other one was now going to be done by CVS/Caremark, and that's where things get interesting.
Before getting into that, a special shout-out to WHI for not notifying us or are insurance coordinator that we weren't contracted with your version of Medicaid. It was real nice going through half the day Monday getting the message "Pharmacy not contracted on date of service."
Now back to CVS/Caremark's Medicaid. This one was a spectacular fail, mostly because there was no consistency as to whether a claim was going to go through or not. The first couple went through like they should. I added the new plan in, put in their ID, the proper group, and voila! Success.
It was downhill after that.
First was the 25 minute phone call that ended in us adding a "1" at the end of the ID (that wasn't on the card), making sure the first name wasn't shortened, and adding their middle initial into their profile. Then it went through. After that, it was the double-bill debacle. See, we should be able to bill their primary insurance, then send the copay to whichever Medicaid they have so that their copay is $0. Well, it didn't work. It told us to submit to a different processor that CVS/Caremark uses for this reason, only to watch it reject again for non-matched cardholder/group reasons. After an hour and no resolution from the help desk, my pharmacist gave up and allowed the patient to try and take it somewhere else, where I'm sure they still had a ton of problems.
In short, it was a mess and we aren't very busy. The pharmacist at my retail job posted on Facebook how he was swearing the whole way home because of this particular version of Medicaid, thus confirming my belief it was the insurance's fault for all the problems, not ours.
Today has been better as we've discovered we can use the original Medicaid ID to run them through with less hassle than trying to use their new ID. I'm convinced this wasn't working yesterday and was implemented overnight because they got tired of all the phone calls they received.
Oh, and let's not get started on the formulary changes that have taken place now that the three Medicaids have split off. Stuff that was covered a month ago under the regular Medicaid is not covered anymore, even something as simple as Seroquel. Medicaid itself decided to kick us in the pants and change some of their formulary items just because, well, we don't know. I guess they think it's fun to watch doctors and nurses call in to request prior authorizations on things that had been covered for the last three years.
This is all taking place a month from open enrollment for Medicare Part D, which hasn't been as bad the last couple of years as it was when it was first introduced.
Then in January, a lot of pharmacies get to endure the "my insurance changed at the beginning of the year but I never got a card" circus.
Luckily in my job, we don't do a lot of private insurance so that's not too much of a concern. Most of our clients are Medicaid/Medicare recipients, so once we get past November, we're generally in the clear.
Except for the spenddowns.
I hate spenddowns.
I don't mean to sound bitchy about some of this stuff, but it's much more complicated than it needs to be.
Hopefully there are no more curveballs thrown our way.
I have enough trouble with fastballs.
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