Practices must create a system to deal with PBM drug denial
KOLOA, Hawaii — In today’s pharmacy benefit management environment, it is costing practices more staff time and money to simply get the right drugs to their patient, but the alternative is an angry, unhappy patient, according to a speaker here at Hawaiian Eye 2020.
“Staff working with PBMs must be advocates for your patients,” said Patti Barkey, COE, chief executive officer of Bowden Eye and Associates.
“This is one of the areas where there are a lot of things that are out of our control but at the end of the day, the patient experience is very much expected to be in our control by the patient.”
She warned of this scenario: A patient is given a prescription, goes to the pharmacy to pick it up and is told they can’t have it, without ever having been told that could happen.
She encouraged attendees to create systems and processes to streamline addressing drug denials, prior authorizations and the review of alternatives.
“We have to create systems in our organizations to better understand this process,” she said. “If you look at the struggles taking place, ... we can’t get the right prescriptions to the patients a lot of the time. New drugs are coming out and new things are getting approved, and we know the patients need them. My senior physician likes to say the prescribing of drug is just a suggestion these days – it is not an order.”
The insurance companies are in control she said.
“We have to understand this because the patient is blaming us. They are not blaming their carrier or not blaming the government,” she said.
Barkey said payroll is going up because practices have to hire staff to handle these circumstances, not only to deal with denials but also with prior authorizations.
“Your staff may be taking shortcuts and if you aren’t aware of shortcuts they are taking,” the patient may be receiving drug alternatives the physician does not feel are appropriate, Barkey said.
Staff may be accepting the “alternate suggestions without your knowledge,” she noted.
“We had to remind our staff that they are not prescribing physicians,” she said.
Barkey’s practice now has a process for reviewing alternatives, including a process to have “alternatives already designed so we know what they are” and a process for generic acceptances.
Barkey’s practice provides patients who received a prescription with a document that notes that a prescription may or may not be available at the pharmacy based on “their” coverage, with “their” coverage being key.
She said patients are told that the practice will do everything possible to help the patient but the patient “needs to take control of the situation and help us as well.”
While there are now specialty pharmacies to help in certain circumstances, patients are fearful of unknown calls and drugs delivered to their house from an unknown source. She said it is imperative for a practice to inform their patients of these helpful services and how they work.
Finally, she highly recommends that staff encourage patients to bring their prescriptions to follow-up visits. – by Joan-Marie Stiglich, ELS
Reference: Barkey P. Panel discussion: Evolution of payer policies. Presented at: Hawaiian Eye 2020; Jan. 18-24, 2020; Koloa, Hawaii.
Disclosure: Barkey reports no relevant financial disclosures.