Top Street Skills for the Community Pharmacist

When I first graduated from pharmacy school, I thought I was well prepared for practice; after all, I had just gotten all my guidelines down for the latest in heart failure, diabetes, and chronic obstructive pulmonary disease (COPD). I had practiced counseling patients and had my newly-minted certificates in MTM and immunizations. I also had my 5 semesters of pharmacy compounding down and was comfortable making both sterile and non-sterile preparations to work in a variety of settings. I first took a job with Walgreens in upstate South Carolina and quickly realized I was seriously lacking in what I call pharmacist "street skills."

Thankfully, our graduating class had an incredibly supportive district manager and excellent pharmacists to mentor us and bring us up to the level of a competent, functioning community pharmacist. We spent part of the time prior to being licensed helping cover technician vacation and part of the time training with the other pharmacists, which I realize now was exceptional — the majority of other jobs I’ve taken I was thrown right in the mix to figure it out. In my opinion, these are some of the top skills new graduates should focus on (unless they’ve had significant prior community experience):

People Skills

In addition to counseling, how do you deal with a patient that is really rude to either you or your staff? What if they are openly hateful or racist? What if they forge a prescription and walk around the store panhandling to pay for their controlled substances? I’ve been in stores where all of the above has happened. I once had a guy come in through our ER, make up a Social Security number, name, and address, get a prescription for Percocet, and come to me to fill it. He told me that his ID was stolen recently and presented his arm band from the ER. Because we are owned by the hospital and service a lot of surgery patients, we accept the hospital band as sufficient ID (patients are told before being admitted to leave everything at home so discharging patients would not ever have an ID). While we were filling, I believe he went outside to beg for money to pay for the medicine, and once he got it he cut the chain on a bike and stole it to leave the hospital. The bike was actually owned by a security guard and he had asked the security guard before doing that if he could borrow their bolt cutters. Pharmacy school does not prepare you for these types of situations.

I have also had to handle 3 forged prescriptions (that I at least knew were forged) so far in my career. Thankfully the first one happened while I was training at Walgreens with a more experienced pharmacist. For those that have not handled these before, here is my step-by-step guide on handling this:

1. Confirm it is forged: Call the doctor’s office and tell them you think one of their patients has forged a prescription and ask to speak with the doctor. Then, if the doctor says he did not write that quantity/date/etc. on the prescription, ask if you can fax it over to his office to confirm, and keep the fax confirmation. Then call back in a few minutes to confirm it is forged and document either the doctor or the representative you spoke with.

2. Stall the patient: Tell them the printer went down and so there are a few delays or whatever you need to tell them. The goal is to keep them in the store.

3. Call 911: Yes this is an emergency call, because it is time sensitive and forging a controlled substance prescription is a felony.

4. Once the police arrive, document everything: You will be giving the original prescription to the police as evidence, so you want to make copies of everything you give (including the fax confirmation) for your risk management department. Document the event in the error reporting system so it is there. Also get the name and badge number of the police officer that arrived.

5. Follow up with other legal requirements: In Florida, for example, you must report to the Board of Pharmacy and local police within 24 hours.

Thankfully for new grads, I really believe the people skills get better over time; if you are able to work shifts with other more experienced pharmacists, however, then use that as an opportunity to see how they handle those tough situations. Over time you will develop your own style.

Insurance Skills

Yes, insurance! Pharmacy school did not teach you anything about how to handle them and now you must learn. My best advice is to practice a lot and learn from the technicians you are working with rather than relying on them to fix it. Most of us could write a book on insurance issues, but here are some basics:

1- Computer system pre-edits: Every computer system I have worked with has what are called ‘pre-edits’ built into them, which means that if the system thinks something is wrong with the prescription then it will put the prescription into rejection before billing the insurance. It is there to save the pharmacy money on ‘switch processing,’ which is the fee charged every time the intermediary (or ‘switch) sends a claim to the insurance. Oftentimes this is helpful, but there are times when it is obviously wrong and you need to bypass it. For example, just the other day I was trying to fill four patches of Transderm Scop and got a rejection that said “Must bill in quantities of 24.” The system was trying to tell me I shouldn’t break the pack (most of us do). To override these pre-edits, you can put a “9999” or sometimes “9998” in the Prior Authorization field. Once I did that, it bypassed this stage and went directly to the insurance and I got a paid claim. Another example of a pre-edit is a look-alike-sound-alike rejection, which I often see for Lamisil/Lamictal. Once confirming the drug, you can override it by putting “6666” in the Prior Authorization field (it is possible there are systems with different codes, but these are the codes I have used with all the systems I have ever worked with).

2- ID numbers: Insurance usually doesn’t want the entire ID if there are a bunch of letters on the front, so you need to learn specifics to each insurance. One pearl I can tell you is that Blue Cross/Blue Shield is almost always the last nine figures, so if the card says “FGYH12345678” a good first try would be “H12345678.”

3- Other Coverage Codes: Necessary for billing more than one insurance or a coupon. If the primary insurance paid, you need an OCC of 2 or 8.

4- DAW codes: If the patient requests brand and you need to use a DAW 2, then you have to document ‘patient wants brand’ on the face of the prescription, or you are at risk for a chargeback.

5- Days Supply calculations: Mistakes in this area are very common and if the insurance catches a mistake it will lead to a chargeback. One I see a lot is with diabetic testing supplies. Physicians will write to test once daily and give a box of 100 strips and 100 lancets. If an item comes in a smaller package though you have to give it. So if insurance pays for only 90 days at a time, you are able to give 100 lancets (I don’t think I’ve seen lancets come in smaller boxes) but you have to give a pack of 50 strips for a 50-day supply because it is available that way. If you bill a box of 100 strips for a 100 days supply you could get a chargeback from the insurance on an audit. Same thing for testing three times a day (you must give 200 strips for a 66 days supply), etc.

Package sizes and storage

What is one Symbicort in the computer? What about Ventolin? Which items are refrigerated? Be very careful with these types of things until you get used to it. Symbicort 160 (120 puffs), for example, is usually expressed as 10.2 grams in the computer and Ventolin is 18 grams. And no I did not know that at all when I graduated, nor did I remember that Combipatch was refrigerated.

Conclusion

A common theme in all of this is that your experienced technicians and pharmacists have a wealth of knowledge, so listen to, respect, and learn from them! Also, for safety and accuracy, maximize the use of your computer system. In doing so, you will better be able to help your patients and will become a better and more well-rounded pharmacist.