Price Checks, Test Scripts Can Cause Errors

The practice of determining insurance coverage and checking medication prices prior to sending a patient to the pharmacy is common in physician offices and some hospitals. The intent is to avoid prescribing something that the patient cannot afford. Unfortunately, many hospitals and offices seem to check prices by transmitting “test orders” or calling the patient’s pharmacy and having the pharmacist enter a prescription and run it through the adjudication process to obtain co-pay information. However, they likely do not realize the patient safety risks and system vulnerabilities that can result. In fact, this practice has led to close calls and actual improper dispensation of medication to patients. Examples of reports submitted to the Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (ISMP MERP) follow.

Case 1. A pharmacy received an order for rivaroxaban for a patient with an active warfarin order. When the prescribing resident was notified about the duplication, he said that he meant only to see whether the prescription would be covered by insurance.

Case 2. A patient contacted a clinic for a warfarin refill. However, the nurse noticed that both apixaban and warfarin were on the patient’s medication list. Review of the notes in the electronic health record (EHR) indicated that the clinic had sent a test script to the pharmacy to determine the co-pay for apixaban. Apparently, that prescription was dispensed, and the patient took both medications for about 3 days before the error was discovered. Luckily, no harm occurred.

Case 3. A pharmacy technician submitted a claim after a patient requested information to determine whether Genvoya, which had not yet been prescribed, would be covered. This patient’s insurance approved the medication, and a label was printed and the prescription was filled and dispensed. The patient called his physician about the medication, and the drug was canceled before the patient took the medication.

Case 4. A hospital recently reported an event in which a prescription for a direct oral anticoagulant was called into the pharmacy for price checking but was inadvertently not canceled. Because the cost was high, the patient was later discharged with a paper prescription for warfarin. Unfortunately, he subsequently received both the direct oral anticoagulant and warfarin. The patient was later readmitted to the hospital for bleeding due to excessive anticoagulation.

Because of the variety of insurance plans, many hospitals and physician offices feel forced to rely on outside pharmacies to check co-pays and insurance coverage. Direct calls to the patient’s insurance providers often take a great deal of time and therefore are not always practical. The experience is not unlike that of pharmacy employees when they call insurance companies and pharmacy benefit managers (PBMs) to address any barriers or rejections encountered during the adjudication process. However, the sending of test prescriptions to the pharmacy is an unsafe workaround for a broken benefit verification system. Ideally, prescribers should not send test prescriptions, and pharmacies should not accept such prescriptions.

In 2016, to help spread the word on the unsafe practice of transmitting test prescriptions to pharmacies, Surescripts, which routes prescriptions electronically to pharmacies, sent a customer bulletin to pharmacy and EHR vendors, warning them about errors. The company asked that EHR vendors and their end users (practitioners) ensure that test prescriptions not be sent in the live environment. Since then, Surescripts has incorporated this recommendation into its E-Prescribing Quality Guidelines.

WHAT CAN PRACTITIONERS AND PATIENTS DO?

Many EHRs, at least in outpatient settings, include functionality to access health plan formulary information, as well as to electronically submit prior authorization requests directly to the health plan before transmitting a prescription to the pharmacy. Prescribers should maximize the use of these capabilities if available in their application or upgrade EHRs. Patients may also be able to access coverage, cost, and other information online through their insurance company’s portal. Otherwise, the patient, the prescriber, or a prescriber-designated individual should call the insurer or PBM to determine coverage before sending the prescription to the pharmacy.

To better support patients and practitioners who call, insurance companies and PBMs need to improve the capacity and responsiveness of their customer service to decrease wait times and provide adequate information.

Those who experience errors or near misses with electronic prescribing should submit reports of these issues to the ISMP MERP at ismp.org/MERP.

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.

REFERENCE

E-prescribing quality guidelines, version 2.5. Surescripts website. surescripts.com/docs/default-source/pressrelease-library/e-prescribing-quality-guidelines.pdf?sfvrsn=fb807dca_38. Published September 2018. Accessed September 17, 2019.