The past few months may have found Deseret Healthcare inundated with complaints about the insurance company's prescription-drug claims service, but that may be improving, Utah Valley pharmacists say.
Independent pharmacists recently met with insurance officials to relay the problems they have had with PAID, Deseret Healthcare's prescription service. Since then service has improved, said Mike Bernsten, owner-pharmacist of Provo Pharmacy.Deseret Mutual Benefit Association, of which Deseret Healthcare is a part, in January changed its prescription services from Pharmaceutical Card Systems to PAID, in an effort to keep down premiums for workers and employers, but pharmacists have complained about slow claims processing and quick claim rejection with the new service.
The change has particularly created problems in Utah County because the majority of people DMBA insures live in the county, said Michael Stapley, DMBA vice president of benefits. DMBA insures employees of entities affiliated with The Church of Jesus Christ of Latter-day Saints.
"Where DMBA is a major insurer at BYU, the impact in a community like Provo has been unbelievable," said C. Neil Jensen, executive director of the Utah Pharmaceutical Association. "Insurers are pocketed around the rest of the state, but Utah Valley has been hit the hardest."
Claims are now being sent electronically to PAID in New Jersey, hot lines have been set up for the area and a specific person at DMBA handles problems with certain drug stores.
"I have no complaints now," Bernsten said. "DMBA bent over backwards to fix the problem and help us work with their system. They found that they went with a company that was not ready to handle their volume."
No change in services would have made it difficult to stay in business and compete with chain stores, said John Bawden, owner-pharmacist at Edgemont Pharmacy in Provo.
Bernsten said he has had to drop prescription services in the past because "I've got to pay my bills. When I'm paid every three months, I have no choice but not to accept them."
The DMBA change from PCS to PAID created myriad problems because local pharmacists were not adjusted to the new system, Jensen said.
Some pharmacies have been affected greatly because they are near Brigham Young University and heavily used by DMBA participants, Stapley said.
Bawden's pharmacy is one of them. More than 30 percent of his customers are insured through DMBA. "My cash reserve has taken a $10,000 nose dive," he said. "The money is there, but it has been tied up with PAID."
Stapley said, "Our philosophy as a company is that we work very hard to have a good relationship with our providers and help them understand the claims process. Those who are used to working with PAID have not had a hard time adjusting."
Pharmacists are still working with DMBA to change its pharmacy dispensing fee and reimbursement level.
DMBA's program pays pharmacists 90 percent of the drug cost plus a $2.50 dispensing fee. Historically, the company paid 100 percent plus a floating dispensing fee.
The change was made this year after seven organizations proposed such fees.
"We didn't set the dispensing fee and reimbursement level," Stapley said. "We received RFPs (requests for proposal), and we responded to the market. We only had one out of seven that was higher. It's our fiduciary responsibility as a trustee to keep premiums down."
The real dilemma comes when DMBA takes 10 percent of the average wholesale price away from the pharmacists, which is their earned discount, Jensen said. "Now they are forced to eat 10 percent."
Jerry Ollerton, owner and pharmacist of Art City Pharmacy in Springville, said, "Wholesalers give us a discount if we pay on time, but we have to pay them every two weeks, and when we don't get paid for 60 or 90 days at a time, you can see what happens to the cash flow."
If something isn't done, independents will be phased out and only chain stores will exist, he said.
DMBA could have gone with a specific chain for prescriptions, Stapley said, but to "meet our fiduciary responsibility, which I think we do, we provide independents with an opportunity for services."
The company continues to deal with chains because an informal study of those insured by DMBA found that the majority go to chain stores to fill prescriptions, he said.
Pharmacists have also expressed concerns about DMBA's mail order program and the problems it breeds. Stapley said DMBA may redesign the program in the future.