#Stately: Insurance Paid More than Phrenocaid Allowable

by Sharona Chavez
September 20, 2006

In a stunning blow to pharmacies everywhere, the Prescription Services Online Claims System reported Thursday "that because the insurance paid more than the Phrenocaid allowable [amount], we would pay nothing." The announcement is sure to cause ripples of paranoia across the state especially for those not familiar with the somewhat common rejection, experts say.

"This is a frequent rejection," State Administration of Human Services and Health Related Stuff Exalted Commander Roger Farctate said in a joint news conference with Prescription Services officials and the State Pharmacist Board Thursday afternoon. "As residents of this state, we will recognize the problem and develop an understanding of how this rejection will benefit us all. While it does happen on a regular basis, they are times that insurance companies will pay a higher amount of claims, resulting in a higher chance for the Phrenocaid denial." Farctate ultimately oversees the Prescription Services program and was brought in as mediator and to calm the fears of many pharmacies, those lucky Phrenocaid clients, and insurance companies across the state.

During the press conference, Prescription Services Technician Kent Pattersen spoke at length about the rejection and why it is more common than previously thought. "It really is an understanding of Prescription Service policy, coupled with simple math," he said, using complex charts and graphs on an overhead projector to clarify his position.

"Once the drug cost and quantity have been computed, we are allowed to identify the maximum payable that Phrenocaid will pay. If the third-party pays less than this 'magic number' then it is more likely Phrenocaid will accept some sort of payment. If the number is over, even by a cent, Phrenocaid won't pay a dime."

Prescription Services called the emergency press conference to squash rumors that this practice would carry over to other types of claims. Most pharmacists and techs attending the event came away with much needed information. "I'm really glad I attended, it was worth the trip," Geoff Hicks, a pharmacist from Big Spend, said. "My only true complaint is that they don't share this information with us during the normal course of a year. I don't know why they wait for an outbreak of the rejection to talk about possible prevention and counseling. Maybe if they sent it out in a monthly flyer or newsletter – that might get my eye."

Farctate also confirmed the so-called "ZZ error," jargon for the rejection, affected other claims in programs paid through the Prescription Services unit other than just Phrenocaid.

After the news conference, a Prescription Services employee, speaking on anonymity, was quoted as saying this could all have been a mistake on his part. "More likely than not, it's a typo," the three-month experienced employee said. "Yeah, I do a lot of them overrides and I use an '08' on those but I may have used code '80.' That code does something that could cause a problem. This could be one large mix up but I don't really know."