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Health Care: The Mess That Gets Messier

Category: Minnesota Politics
Posted: 07/16/07 14:22

by Dave Mindeman

Alright...word of warning. You are about to get another health care rant. This is absolutely true...its gospel. I am a pharmacist and if anyone ever tells you that market forces are the solution to our health care mess --- please give them a fat lip for me, because it is crap.

I have a customer... we will call her Jane Doe. She used to be on Minnesota Medical Assistance but when our "President" came up with that "wonderful" Medicare Part D pile of bull, this woman's prescription program was shifted to that program. She didn't have a choice about switching to Medicare Part D, but she did have a few choices of carriers within the system.

She decided to use a program sponsored by AARP. Seemed like a good idea....AARP works with seniors all the time. However, AARP does not administer the program. No, they farm that out to a Pharmacy Benefit Manager... in this case it was RX Solutions.

This woman's coverage started in July, 2006. We had a glitch that occurred at the end of that year, but a phone call to AARP seemed to fix it. Everything for 2007 was working fine.... until today.

An on-line claim for her medications came back with the ominous message -- "Coverage terminated -- 12/31/2006". I love the word terminated.... sounds like a death sentence. Anyway, I helped her out and called the customer service number on the back of the card which landed me with the service desk at AARP. After giving them my store's ID number, my full name, the customer's medical ID, date of birth, etc, etc., AARP said, "OK, I see her coverage. You will have to call RX Solutions to find out the problem."

They gave me another toll free number and off I go to RX Solutions. Again, I go through the litany of identification numbers and names and they check their database. The response came back, "We have no record of this ID having coverage with us."

Having been through this many times before, I know that if you don't start asking questions, this will end their part of the conversation. No record...no responsibility. So, I started piecing things together. The conversation went like this:

Me: "No record at all?"

Service Desk: "Our record shows termination on 12/31/2006."

Me: "But she has been getting Rx's via your insurance since the first of the year."

Service Desk: "I don't see how that is possible."

Me: "OK.. can you check back to the last claim on 6/18/2007? That should show coverage was given."

Service Desk: "I'll check with my supervisor."

Now we have about a 10 minute wait on the phone. Meanwhile, other customers are backing up and I try to get some of them taken care of.

Service Desk: "Yes, it looks like previous claims for this year have been going through.... however, it seems that someone changed the expiration date on the coverage."

Me: "Who would have the authority to do that?"

Service Desk: "I don't know. There are no names on the adjustment."

Me: "So, can she get coverage now."

Service Desk: "No, the coverage terminated on 6/18/2007."

Me: "So you are telling me that coverage ended on the date that her last claim was filed?"

Service Desk: "That's correct."

Me: "But AARP says she has coverage. She has a card that says she has coverage. Can't somebody fix this?"

Service Desk: "We can't make those type of corrections. She will have to call her service provider and find out what the problem is."

Me: "And that is not you?"

Service Desk: "No, I said she will have to contact the service provider.... we are the service administrator."

Me: "Oh. Alright, so we need to get AARP to resolve this?"

Service Desk: "That is correct."

So, getting nowhere fast with that, I call Jane Doe up and try to explain where we are at. Since I had already talked to AARP and was told the coverage was valid, I told her to call the AARP service department and try again. That is where we stand now....

middle of nowhere.

This isn't a rant about AARP in particular... I go through similar problems with just about every carrier involved with this idiotic system. Nobody gets it right and really, nobody has any incentive to get it right. If the claim is delayed or denied by mistake, who comes out ahead? Think about it.
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