The Pharmacy Chick

Flying the coup in retail

“It’s covered” doesn’t mean ” It’s free”

Filed under: Uncategorized — pharmacychick at 9:05 am on Tuesday, June 25, 2013

Effective communication is probably one of the most important attributes to being a good pharmacist.  You HAVE to be able to convey a message that your patient understands properly and in the proper context.  Time and time again I have said X to a patient who will immediately hop on a cell phone and convey Y to the person on the other end with a message that not only is inconsistent with what I had just said but often completely inaccurate.  Doctors have called me unable to understand what a patient was telling them because they managed to mangle a message.  Its amazing really.  Therefore I will often speak in first grade English and ask them to verify understanding on things that really matter.

ONE of those things is the cost of their copays.  to many, “covered” means “free” and that is never ( or seldom) the case.  Nothing expensive is ever labeled, opened or otherwise adulterated until the patient fully knows what the cost is, has agreed to pay for it, and is standing at the counter asking for it.  I am done with being stuck with drugs I cannot use because somebody taped a label to it.  Thankfully with the advent of integrated main frames I can see what other stores use and can sell it to somebody who can actually use it. Never the less, Id rather not have to do that.

Recently I got bit by the “covered but not free” bug myself.  Mr Chick had been having some dental problems and finally went to the dentist who delivered the grim news.  ” You need a crown”.  Lovely.  We had the dentist do all the appropriate things by having it pre approved and by all intents and purposes, we did everything by the book.  The receptionist called me a week later and said ” we have everything pre approved.  Its covered and you have a 50.00 deductible.”.   Now had I had my rph thinking cap on, I might have said…” Covered…as in 100%?” but something in my brain was turned off and I took her words at face value…so did Mr chick, also a pretty smart insurance savvy guy. So we went into it thinking we had to pay 50.o0.

The big day comes and lo and behold he needs two crowns because the tooth that was cracked was hiding a crack exactly opposite it in the adjoining tooth. so both needed to be done.  My heavily sedated sweetie hardly knew what happened because he was so out of it.

A couple of weeks later the ” explanation of  benefits” came in the mail.  “AMOUNT BILLABLE TO PATIENT: $ 1150.00”.

Yessiree. Crown was covered….at 50%  and 50.00 deductible…a little fact that the receptionist failed to mention.  But nevertheless, still my responsibility.

Now, thankfully, we have the resources to pay this kind of bill.  Not everybody does and it served as a timely ( if not costly) reminder that even the intelligent and relatively informed can be misled.  Would it have changed things for us? Probably not, he needed that crown…both of them.  But there are a lot of people who might have had a bill like that be a life changing mess.

Yes, communication is important.  Remember that!

10 Comments »

Comment by Loren Pechtel

June 25, 2013 @ 9:30 am

That’s a pretty expensive crown and I doubt the omission of mentioning the 50% was an accident. I’d be looking for another dentist.Loren, I am quite sure it was an accident. We go back a long way and have a solid history together. It was a communication issue…and had I referred to our insurance manual ( handed out every year) I would have seen that crowns are covered…at 50%.

Comment by Dr. Apothecary

June 25, 2013 @ 5:42 pm

Yeah, I’d definitely be complaining to the dentist’s office, and depending how they responded, I might consider a different dentist. I’d still, of course, pay the bill, but $550 or so is a LOT different from $50, and since they pre-billed it, they actually mis-lead you. Granted, they didn’t know about the two crowns, but you would have still been charged the 50% either way.

My dentist has always told me exactly what I owe beforehand, and there’s never been any mistake.read my response to Loren. It is what it is. He is a good friend and an excellent dentist. I dont think there was any intent to mislead 🙂

Comment by Maggiepie

June 25, 2013 @ 6:53 pm

It aggravates me that our dentist knows exactly what our plan pays. We always tell them that we don’t want the Cadillac of dental work. Somehow….magically, our dental work just happens to come out about $200-300 above what our plan pays. I really like the practice, but may have to change providers due to their greediness.

Comment by Mary

June 27, 2013 @ 11:06 am

Having had to have several crowns I was not at all surprised by your cost. My dentist’s receptionist and I were both (pleasantly) surprised when for a few years my insurance covered 70% on crowns. BTW, encourage everyone you know to use that fluoridated water for their children under six or supplement with vitamins. That is why have had so many crowns. Or, so multiple dentists have told me.

Comment by WarmSocks

June 28, 2013 @ 10:50 pm

Ouch! But, if that $1150 is for two crowns, I’m impressed. Our 50% on crowns comes to about $850. Dentists in WA are reputed to be higher than other places. I know someone who found it less expensive (quite a few years ago) to pay airfare to Virginia and pay cash there than to have dental work done in WA.

Comment by LibraryGryffon

July 2, 2013 @ 6:51 am

Oh, yes, I know this well. That’s why I have two huge gaps in the back. I need a four tooth bridge on each side (it’s a long story involving orthodonture, having been a tetracycline baby, and recurring abscesses) and even with two insurances, I would still have to come up with about $1500 just to get one of them done. Even at 50% coverage, 50% of a bridge is a lot more than the maximum either insurance will pay out.

I’ve noticed that most dental insurance has a maximum payout per year of around $1000, which is the same as 25 years ago, although dental work has gotten way more expensive. In reality these days, dental insurance isn’t so much “insurance” as a pre-paid care plan.

Comment by JS

July 6, 2013 @ 7:12 pm

How have you been? So glad to know another person that takes full responsibility for their medical care. It’s our responsibility as the patient (I am NOT in the medical field) to know our coverage and benefits. It’s easy to forget to ask when we’re forced to do 100 things @ one time while standing on our heads and spitting wooden nickels. But what they probably meant (and I KNOW you KNOW this) was everything is covered @ the rate your insurance dictates, in Mr. PC’s case, 50%. I’m sure your Dentist didn’t train his staff to screw you! As you said, you have a long history with him. But it all comes down to patients taking responsibility. I get all my own pre certification info once my MD says he/she has it; I file it for my own records and it’s come in handy a few times. Take care! JS

Comment by C

July 7, 2013 @ 5:09 am

It took me years as a military wife to understand the darn (medical/insurance, etc) system-we’re retiring unexpectedly (as in-let’s retire rather than spend one more moment dealing with the disaster that is this job)/feelyourpain

Comment by Garrick Dee

August 5, 2013 @ 8:18 pm

That’s the reason why my father in law always comes back here to the Philippines and have his tooth fixed even if he has health insurance over there. If the doctor knows you’re covered – they’ll do a procedure you’ll probably not need just to get extra – sad reality 🙁

Comment by Dr. Pullen

August 8, 2013 @ 10:42 am

It’s easy to blame the dentist, and I see that you don’t, you accept responsibility though emphasize the need to ask the right question and you as the provider of service try to be accurate and clear in your communication. This whole concept of covered, copay, deductible, and prior-authorizations is incredibly ambiguous and convoluted. Third party payers. You can’t live without them, though some are now trying.

RSS feed for comments on this post. TrackBack URI

Leave a comment

XHTML: You can use these tags: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>