The more I use the healthcare system the more I realize the issues with the system. While I was preparing to take my new job, I went temporarily on COBRA. I ended up with a few paper claims while I waited for my new insurance cards and due to an eligibility file issue which the MCO or the TPA made.
Now, I am trying to get reimbursed for the 5 prescriptions for my family. After filling out the forms and getting the pharmacist to sign them, I faxed them to my payor. A month later, I have heard nothing so I called them. They inform me that they have been processed, and I will get a check less my copay. (Sounds great.)
Then, they walk me through the claims. In one example, I paid $95 for a generic drug. Well, their negotiated rate with the pharmacy for that drug is $22. Taking out my $10 copay, they are sending me a check for $12. WAIT! What about the other $73 that I spent (times 5). I got a nice lecture on negotiated rate versus retail which I explained to the woman that I knew.
(Here is a WSJ article on generic pricing. This is where the margins exist. Cash customers often pay the average wholesale price plus while the negotiated rates for the payors are usually 60% or more below the average wholesale price. Here is a blog discussion in the Freakonomics area about prices ranging from $12 to $117 for the same generic prescription.)
All I care about is getting my cash back. They can refund my premium, claw it back from the pharmacy, or write me a check. They didn’t get me my cards or set me up right (or the Third Party Administrator (TPA) didn’t). I don’t care.
After a second call, they inform me that I can appeal it and will hear in 30-days at which time I can appeal it again. It makes me ask what the problem is and how this works for people with limited cash flow. You have to pay and wait 3 months only to likely get turned down. This seems like a major flaw in the process. Why offer paper claims if you don’t get your money back?
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