“Watch out…here comes the term-auditor”

Being a pharmacy intern at Blue Cross has many great perks. Not only do I get to learn the meat and potato of my own team (Pharmacy Networking/Contracting), everyone always seems to be presenting me their best offers.

“Best offers” right now would surely have to be the different experiences that I’m seeing and learning everyday in the Managed Care world. And for the first time, I got to go on an auditing trip—a side of pharmacy business that I never thought I would be part of.

The way Blue Cross carries out its auditing process is different than most other insurance companies. While most insurance companies focus mainly on the expensive drugs (such as specialty drugs; ie cancer drugs) during their auditing process, Blue Cross is out to ensure that ALL drugs are billed the correct way.

Before going out to the “chosen pharmacy,” the auditor would randomly select a set number of prescriptions that have been billed to Blue Cross within the last year. Upon arriving at the pharmacy, the auditor would request few more random prescriptions to be pulled. This way, the process consists of both prepared and surprising elements that will ensure the fairness of the auditing process.

From there, the auditor will go through the hundreds of prescriptions that have been pulled, and compared them with the billing records one by one. If ANYTHING is different from the billing records—patient name, medication, quantity, missing signatures, etc, the pharmacy is subjected to a fine OR an educational lesson (aka a simple warning). If certain violations are found, the financial penalty will be EXTRAPOLATED for the entire year worth of claims filed. Such extrapolation process can be good and bad—depending how you look at it.

The actual pharmacy visit was more civil than I had imagined. We were handed the requested scripts right off the bat and were left alone to work on them for the rest of the day. Perhaps most people figured that a happy auditor can only means a happy turnout, so they all left us be. I invite whoever has been through a pharmacy auditing process to comment on this entry and let me know what it was like to be on the pharmacy side.

Overall, the trip was an experience that I will hold dearly to my heart as I progress through my career. Whichever side I end up being working for, it’s always good to know the proper rules so there’s nothing to worry about. In addition, this experience continues to amaze me just how many opportunities are out there for pharmacists.

“Insurance = Evil”? Think Again.

Hi all! My name is Tony Lin and I will be a P3 in September. I apologize for those that have been dying to hear how “brain-washed” I am with my Managed Care (aka insurance company) internship…it’s better being late than never!

This summer I will be interning at Blue Cross Blue Shield of Michigan (BCBSM) Department of Pharmacy Services.

Perhaps for those that have worked in community pharmacy (or from your own personal experience), many people often view the insurance companies as these evil groups that never seem to pay for any drugs for the patients. To tell you that any “Prior Authorization” or “Rejection” messages are being displayed on your pharmacy computer screen only after complex logical calculations might be hard for you to believe. Well, the analogy I would use here is that many people think all pharmacists ever do is count pills—try again…it IS more complicated than just that!

In a nutshell, an insurance company (aka a Health Plan) pools financial resources together from clients (such as your parents’ employers) and use them effectively in paying for the claims (prescription drugs in our case) filed by beneficiaries. With limited resources, strategies must be implemented to be cost-effective.

While most of the public think that drugs are like cars—the newer the better, us pharmacists know better and realize that it is not always the case. Many drugs can easily cost hundreds or thousands of dollars per prescription or per unit. This is why insurance companies set Prior Authorization in place, ensuring generic drugs (which work just as well as brand names) or other more inexpensive alternatives have been tried first.

My specific duties this summer are to be with the Pharmacy Network team. The team prepares, reviews and manages all contracts from pharmacies in the state of Michigan. No—Blue Cross isn’t the DEFULT insurance for anyone. And yes—each individual pharmacy (chain or independent) must set up specific contract with BCBSM in order to serve patients with Blue Cross plans. More on this will come as the summer goes on.

I’m going to leave you all with few “Blue” Fast Facts:

** Total Employees: 7000 (3000 employees just moved their offices to downtown Detroit from Southfield to join the existing 3000 employees that were already in the city)

** Members: 4.3 million

** Claims paid in 2009: $19.8 billion ($5 billion paid in pharmacy claims)

** 50 million pharmacy claims annually

Did you know?

** Nearly 92 cents from every dollar BCBSM collects in premiums goes to pay for health care services.

** Of the nearly 30,000 doctors in Michigan, more than 99 percent participate with the Michigan Blues.

** Nearly 2,400 pharmacies in Michigan participate with Blues plan prescription drug coverage programs.

** There are 159 hospitals in Michigan. They all participate with the Michigan Blues and accept the Blues member ID card for health care coverage.