Paper Claims – Are You Kidding Me?

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?