Imagine being told medicine you’ve been taking for months is no longer covered! It’s a struggle some Medicaid patients are still dealing with nearly three months after the state upgraded its healthcare payment coverage system.
Most people on Medicaid will admit they live on a fixed income and simply don’t have the funds to pay out of pocket costs for their medications.
After the State of Colorado upgraded two of its computer systems earlier this year, health care providers weren’t getting paid, certain medications were no longer covered and trying to get any type of assistance to sort out the problems took hours!
On a scale of 1 to 10, Kristina Winnett’s medication problem is relative minor.
“My sinuses are plugged up right now,” she said. “I have watery eyes and sometimes itching problems depending upon how high the pollen level is.”
Kristina suffers from seasonal allergies. In the Fall of 2016, her doctor prescribed Ceterizine, a form of Zyrtec.
“All the way up until March 1, I was able to get that medication and then suddenly I couldn’t,” she said.
Pharmacy records obtained with Kristina’s permission show her prescription was recently rejected not once, but twice because of what appears to be a coding error in the state’s new pharmacy management system called “Magellan”. The new system launched Feb. 25.
“It’s so frustrating especially because it (the system) worked beautifully before and now we have a new system,” she said. “I appreciate the state taking care of me and people with low income but now we are in a situation where the patients can’t do anything, doctors can’t do anything and pharmacists can’t do anything.”
To complicate matters, the state also rolled out “Colorado Interchange,” a new Medicaid payment processing system March 1.
Following its launch, thousands of health care providers were not getting paid and sorting out the logistics meant waiting hours on hold.
Marc Williams, a spokesperson for the Colorado Department of Health Care Policy and Financing said despite notifying health care providers back in the Fall of 2015 about the switch over, thousands of providers failed to re-enroll in the system.
Angry providers who were not getting paid then clogged phone lines trying to get their issues resolved.
According to Williams, the call center handling problems for Colorado Interchange had 18 call center agents in March. The center since had to hire 42 new agents to reduce 2-3 hour wait times. To-date, Williams says the center has a total of 60 call center agents.
“That’s not right to put patients in this position with their healthcare over a computer system,” Winnett said.
Pharmacist Barry Patterson with The Medicine Shoppe agrees.
“It gets frustrating because then we have to make calls, it takes time out of our day and the patients have to wait a little longer,” he said. “There is going to be calls we have to make as pharmacists to try and get stuff (medication) approved that maybe was previously approved and it’s not now.”
In Kristina’s case, Ceterizine is listed under the Medicaid “preferred drug list”. Williams did not know why her medication was now being rejected, but promised he would look in to the specific error codes.
Meanwhile, Kristina fears there are other patients with more serious illnesses who are having to pay out of pocket costs to fill their prescriptions.
“When we can’t get our medications, there seems to be a lot of problems like hospitalizations, worsening health and eventually that costs taxpayers a lot more than if we could simply get the medications that just keep us out of those situations,” she said.
Kristina hopes by speaking out, the State of Colorado will investigate every denied claim and coding error so that people get their medication on time.
“Something needs to be done before patients’ lives are put in jeopardy,” she said. “That’s why I came to you. Perhaps we can get a resolution.”
Getting mixed answers:
You may be wondering why we can’t seem to get a straight answer on billing and coding errors.
Williams explained over the phone that because there are so many types of error codes that can pop up, the error has to be evaluated on a case-by-case basis depending on the type of medication being prescribed, the patient’s health care provider, and whether the medication is a new prescription or a refill.
Williams said he cannot comment on Kristina’s case because of patient privacy laws.
What is being done to fix issues with the Magellan and Colorado Interchange systems?
After adding new call center agents, wait times have decreased from 2-3 hours to 2-3 minutes, according to Williams.
At the time Colorado Interchange launched, 42,000 providers had re-enrolled. Between March 1 and May, Williams said an additional 3,000 providers have enrolled. As more providers re-enroll in the system, the number of issues pertaining to health care providers getting paid should decline.
So far, 60-percent of claims processed through Colorado Interchange are approved and paid out. The remaining claims are denied or suspended, pending further review.