Insurance Billing In Pharmacy Curricula: Is This Covered?

By Jordan L. Kelley, PharmD

The first question asked to me as a pharmacist was “Is this medication covered by patient X’s insurance?” After sitting through pharmacology, pharmaceutics, therapeutics, and more – it took me by surprise. However, community pharmacists are asked this question daily and are forced to field prescription drug coverage questions from patients and physicians despite very little education on how to actually deal with these situations.

This wasn’t the first time that the pharmacist’s role in prescription drug coverage was brought to my attention. In fact, I was eleven years old when Medicare Part D was initiated and I became a volunteer to help sign patients up by Part D plans that would cover their medications. It was important that patient in my small town community be able to afford their medications at the local pharmacy. My view of the pharmacist’s job was to bridge the gap in knowledge between the physicians, the insurance companies, and the patients. Yet here I am, years later as a practicing pharmacist, still not completely sure the appropriate resources to identify formulary information. Which brings me to this question – should there be a greater emphasis on prescription drug coverage in pharmacy curricula?

Tackling Prescription Drug Coverage
Pharmacists must know an abundance of information. Health professionals and patients utilize us as drug information resources, patient educators, lab technicians, and medication dispensary experts. Given all that, should pharmacists also be expected to know the intricacies of insurance coverage, prior authorizations (PA), and patient assistance? Luckily, at many hospitals, implementation of social workers and PA technicians has helped triage some insurance-related tasks, but pharmacists are still responsible for troubleshooting medication problems upfront. Managing and troubleshooting prescription coverage issues has become a large portion of many pharmacists’ daily tasks, impacting workflow and workload in a diversity of ways. For instance, if a hospital pharmacist doesn’t help tackle formulary/product selection issues on the front end, then a community pharmacy colleague has to when the patient is discharged.

There is evidence to demonstrate that pharmacists need knowledge of insurance. Studies have found that when a pharmacist is involved with prior authorizations and claims billing, there is a decreased cost and increased compliance for the patient.1,2 Furthermore, a study where pharmacy students educated other health care professionals found that even one lecture on Medicare Part D and cost savings was beneficial in helping decrease patient’s medication cost.3

Pharmacists have significant input on formulary management for insurance companies and inpatient hospitals and are also finding themselves involved with Medicare transitions of care and implementing billing codes.4 However, most curricula do not focus on the intricacies of processing insurance and billing. There are numerous potential reasons for this gap, including the push for more clinical knowledge and the difficulties of constantly changing insurance parameters.

Fitting It All In
As curricula are refined, pharmacy educators should consider the positive impact that insurance troubleshooting skills could have on patients. It could reduce patient anxiety over financial unknowns, make it easier to obtain medications (which could improve compliance), and even impact overall health by facilitating and planning medication regimens that best fit the patient’s insurance parameters. The goal should be for students to feel comfortable fielding insurance questions when they graduate.

Any pharmacist or educator likely agrees that this information should be covered, but the problem lies in how to incorporate it effectively, when there are numerous learning objectives to meet in any course or rotation. Students could develop these skills in a community pharmacy setting during practice experiences, if preceptors prioritized time spent learning insurance over other objectives. Other options are to add insurance claims problems into skill-building and hands-on classes. The solution is not simple, but if inpatient and outpatient pharmacists can decrease stress and anxiety on the physician and patient by taking into account “is this covered?” shouldn’t this also “be covered” appropriately in the curriculum?

Acknowledgements
Special thanks to Dr. Jeff Cain, University of Kentucky College of Pharmacy, for his guidance on this article.

References

1. Leinss R, Karpinski T, Patel B. Implementation of a comprehensive medication prior-authorization service. Am J Health Syst Pharm. 2015;72(2):159-63.

2. Mino-león D, Reyes-morales H, Flores-hernández S. Effectiveness of involving pharmacists in the process of ambulatory health care to improve drug treatment adherence and disease control. J Eval Clin Pract. 2015;21(1):7-12.

3. Stebbins MR, Frear ME, Cutler TW, et al. Pharmacy students teaching prescribers strategies to lower prescription drug costs for underserved patients. J Manag Care Pharm. 2013;19(7):534-41.

4. Thompson CA. Workflow key to providing Medicare transitional care services, pharmacists find. Am J Health Syst Pharm. 2015;72(16):1346, 1348.


Jordan KelleyJordan Kelley is an Internal Medicine PGY2 pharmacy resident at the University of Kentucky Healthcare. Her current research is focused on the renal effects of vasopressin in cirrhotic patients with septic shock and the use of n-acetylcysteine for acute liver failure. In her free time, Jordan enjoys traveling, overindulging at new restaurants, and reading books that make you look at the world differently.


Pulses is a scholarly blog supported by Currents in Pharmacy Teaching and Learning

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