Medicare a mess for pharmacists

Posted: Sunday, August 26, 2001

A bureaucratic battle over filing claims for medical supplies is brewing between Medicare and some local pharmacies, leaving patients in a paper quagmire.

Some local pharmacies are refusing or are reluctant to file Medicare claims for people buying doctor-prescribed durable medical supplies because of the vast amounts of paperwork involved, some pharmacists said.

However, a Medicare representative said it has worked to make the process easier for pharmacies so patients do not have the hassle of sending claims.

Medicare is the federal health insurance program for people over 65, some disabled people under 65 and people with end-stage renal disease requiring dialysis or a transplant. Durable medical supplies includes such things as canes, walkers, commode chairs, home oxygen equipment, artificial limbs and neck braces.

Locally, both Fred Meyer and Kmart pharmacies have Medicare assignments and will file for patients. Ron's Apothecary will not file for patients. Juneau Drug and Foodland Super Drug declined to comment.

Janet Arens, pharmacy manager at Fred Meyer, said it does file for patients but it's a burden, at times, given the volume of prescriptions the pharmacy receives a day and the amount of work involved in filing a claim.

"We don't have to do it, but we do it as a courtesy," Arens said. "And every time we do, we run into problems."

Arens said at Fred Meyer the policy is that patients with prescriptions for medical supplies have to pay the entire amount up front for the supplies. The pharmacy bills Medicare for reimbursement. The patient will then receive in the mail the 80 percent covered by Medicare.

Medicare requires the pharmacist to get a signed prescription from a physician. Arens said this is sometimes difficult because many prescriptions are called in by doctors.

Medicare also asks the pharmacist to obtain quantity and directions for use of the supplies. Arens said this is time-consuming because many of the prescriptions read only "use as directed." This means more time spent talking to staff at the doctor's office and not filling other prescriptions, she said.

During this call the pharmacist has to sift through 20 to 30 diagnosis codes depending on the seriousness of the illness, Arens said.

Arens said the pharmacy doesn't get many prescriptions anymore from people using Medicare for supplies.

Pam Negri, media specialist for Medicare, said Medicare encourages pharmacies to file for patients and has tried to make the system easier through electronic filing of claims.

Pharmacy Manager Scott Watts of Ron's Apothecary said it does not file for patients because of the "nightmare of paperwork." He said he's known claims to take up to six months to get reimbursed the 80 percent the pharmacy pays out if a patient is required to pay only the co-payment up front.

Negri of Medicare said pharmacists are not required to file claims for patients but should. There is a statutory requirement for doctors and hospitals to file claims for patients according to the Omnibus Budget Reconciliation Act of 1989. But, she said, pharmacies were not specifically mentioned in the act.

"It is in the best interest of the patient for the pharmacy to file, otherwise patients have to file paper claims." She said. "To be honest, we're not even really set up to accept paper claims anymore."

Negri said payment on a paper claim takes at least six weeks for a claim that is complete and has no mistakes. But that's rare, and the claim is sent back to the patient to begin the process again, delaying reimbursement.

Also she said Medicare is required to hold the claim for 27 days to prevent fraud when a patient files a paper claim. Medicare holds electronic claims for only 14 days.

Some local Medicare recipients, such as Ellen Northup, said they are pleased with the turn-around time for Medicare claims. A diabetic, Northup said she uses the paper claim to get reimbursed for her supplies and generally has to wait about three weeks to be reimbursed.

Ruth Sherrin, who also uses Medicare, said she has heard of claims taking up to six months to process but said she thinks this is due to filers not having the experience to do it correctly.

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Melanie Plenda can be reached at mplenda@juneauempire.com.



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