Over the years, prescription volume has increased at most pharmacies. This is due to a number of reasons, but one of the biggest reasons is due to expanded insurance coverage. In many cases, this has led to a decrease in patient satisfaction due to longer wait times at the pharmacy.
To understand why there may be delays at a pharmacy, it’s helpful to know the pharmacy’s general workflow. Exact proceedings vary from company to company, but the process is described below. By being aware of what goes on, it’s easier to appreciate which steps take longer than others and where delays may occur in the filling process.
Many organizations and companies work diligently to identify strategies to improve efficiency at pharmacies, but pharmacies in the United States commonly can become straddled by limitations in staffing. Without adequate staffing, it may take longer to implement new changes to the pharmacy workflow to decrease fill times while also maximizing patient safety and prescription accuracy.
The list below describes the workflow for an outpatient or community pharmacy. Processes are slightly different inside of a hospital’s pharmacy (or similar institution).
The list below is broken into 7 simple, sequential steps. Each step may require an intense amount of time and effort depending on the prescription, insurance plan, and/or patient’s overall situation.
1. Pharmacy Receives the Prescription
Prescriptions can be transmitted electronically, via telephone, via fax, and/or via hard copy.
When a prescription is received from a prescriber, issues can arise related to a prescription being fraudulent, a prescription may simply not be valid, or certain required bits of information may be omitted. If any of these incidents occur, it takes time to work to resolve the issue(s) with the prescriber.
Pharmacists tend to prefer electronic prescriptions over the alternative forms due to decreased incidence of fraud, increased levels of safety, and less time spent interpreting sloppy handwriting. In some states like New York, it has even been mandated since 2016 that all prescriptions must be sent electronically directly from the prescriber to the pharmacy (with certain exceptions).
2. Data Entry
Whenever a prescription is received (no matter the receipt mechanism), the prescription must then be entered into the pharmacy’s computer system.
This step is mostly self-explanatory. A pharmacy staff member (pharmacist, pharmacist intern, or technician) can perform data entry.
For every prescription, the pharmacy staff member must accurately enter the correct drug with its corresponding strength, the directions for use must be described and easily interpreted, the quantity and days supply must be calculated, the correct prescriber needs to be selected, and the billing information must be triaged (see step #3 for more details about triaging claims).
Often, there are issues with prescriptions having missing and/or confusing information that is caught during data entry. For example, a prescriber may write for one tablet of medicine X to be taken 3 times a day for 30 days, but then only prescribe 30 tablets. At that time, the pharmacy staff member must take the time to contact the prescriber to see if they intended for a quantity of 90 tablets of medicine X to be dispensed or if they meant to prescribe only a 10-day supply of medicine X.
This is just one example – issues can take many forms. However, correcting these types of simple issues for multiple patients throughout the day (while also waiting to get in contact with these other busy healthcare providers) can cause significant delays.
These sorts of issues can cause a delay for the patient at-hand, but it can also cause delays for other patients as the pharmacy employee is dedicating extra time to solve an issue rather than working on other tasks to be accomplished for other patients. This same trend is true for other issues encountered throughout the pharmacy.
3. Triage the Claim
This step is an extension of data entry. To triage a claim after the medicine details have been typed in, a pharmacy staff member must either bill the prescription to a patient’s insurance plan, bill it to a discount savings card, or have the prescription filled on its cash price designated by the product manufacturer (typically as a last resort option).
Billing a prescription to an insurance plan can be one of the biggest headaches for both pharmacists and patients. Prescription insurance, at its core, is vital – it makes expensive medicines more affordable and possible to receive. Without it, many medicines would be financially unrealistic to purchase. However, dealing with prescription insurance issues is also the task that arguably steals away the most time from a pharmacy’s workflow.
First, the pharmacy must identify the patient’s insurance plan. It is commonplace to encounter issues obtaining the proper billing information for a patient’s specific insurance plan, especially for first-time patients. If a patient is contacting a pharmacy to provide updated insurance information, be sure to have the following four numbers at-hand so the pharmacy can identify the correct plan: Member ID #, RxGroup #, BIN #, and PCN #.
Once the correct insurance plan is identified and selected in a patient’s profile, in the community pharmacy world, there is a luxury of being able to utilize instantaneous adjudication. That is, once a prescription is entered into the pharmacy’s computer system, the pharmacy staff member can immediately know if a patient’s insurance plan will pay for a medicine and for what cost.
Conversely, the pharmacy team member also immediately learns if a medicine is rejected by a patient’s insurance plan. Medicines can be outright rejected if they are simply not on an insurance formulary. At that point, the pharmacy team member must then inform the patient of the issue and proceed to reach out to the prescriber to work on getting an alternative medicine prescribed. Or, as an alternative, the pharmacy team member may elect to find a discount card to utilize for the patient.
However, many medicines are conditionally rejected by an insurance plan rather than outright rejected. Working through these conditional rejections can be arduous. Examples of conditional rejections are prior authorizations (sometimes called preauthorizations), quantity limits, the need for step therapy, etc. To solve these types of rejections, it is typically a tri-fold conversation between the pharmacy, the prescriber, and the patient’s insurance company. These can add significant delays to filling a medication for a patient.
Countless hours are spent toward resolving insurance issues for patients. This is the root cause of many delays in pharmacies.
FAST FACT: for prescriptions billed to an insurance plan, the patient’s copay is determined by the insurance plan – not the pharmacy. The insurance tells the pharmacy what to charge the patient at the register.
4. Pharmacist Checks the Entered Prescription for Appropriateness (1st Check)
This step, alongside step #6, is where the pharmacist demonstrates their value and necessity.
As a baseline requirement, prior to a prescription being filled, the pharmacist must double check that a prescription has been accurately typed into the pharmacy’s computer system (correct drug, correct strength, correct quantity, etc). Similarly, the pharmacist double checks that the insurance information has been accurately selected for the patient as applicable.
At this point, the pharmacist assesses the patient’s clinical picture utilizing their drug knowledge. The pharmacist analyzes the current prescription at-hand and compares it to the rest of the patient’s profile. A pharmacist asks themselves many questions to confirm that the prescription being analyzed is safe and effective for the patient.
Does the patient have any medical conditions that contraindicates the use of the medicine? What drug interactions, if any, will the patient experience between this medicine and their other medications? Are there any duplications in therapeutic drug classes? Is this a medication that has abuse potential, especially if they have other medicines that also have abuse potential? What side effects might the patient have if they take this medicine? Will those side effects be manageable? Will this medicine actually be worth the cost for the patient? Will it actually treat their disease state or illness? Would a different medication be better for them? Would a different dosage form be more preferable?
These are just a few possible questions that a pharmacist may assess for every patient. Answering these types of questions takes time, and it’s important to allow a pharmacist the time to make these important clinical decisions.
Once the pharmacist decides that a medicine will be safe and effective for a patient, they then allow for the prescription to be filled. Making these types of decisions for patients mandates advanced education and training, so a Doctor of Pharmacy degree is a required prerequisite to become a licensed pharmacist.
5. Send the Prescription to Fill
At this point, the prescription has been entered into the pharmacy’s computer system and its use is considered to be appropriate. The prescription can now be filled. At most pharmacies, pharmacy technicians or pharmacist interns are the individuals that physically fill prescriptions.
There typically is a long queue of medications to fill at every pharmacy. Most pharmacies measure their prescription volume in terms of prescriptions per week. A high-volume pharmacy can fill many thousands of prescriptions per week, whereas a low-volume pharmacy may fill only hundreds of prescriptions per week.
The higher volume a pharmacy is, the more prescriptions they have to fill. If there are many prescriptions to fill, there can be delays getting certain medications filled as every prescription in the fill queue needs to be honored and filled in a timely manner.
If a pharmacy concurrently has staffing shortages, it may be difficult for a limited amount of staff to fill a large number of prescriptions in a timely manner while also attending to other necessary duties in the pharmacy. This can lead to delays.
Another common issue encountered during the filling process is not having enough medicine in stock to fill a prescription. In many cases, medicines that are out-of-stock are ordered for the next business day to be filled. However, specialty medicines or medicines that have a certain control schedule may take well more than one business day to arrive. This adds time to the prescription filling process.
6. Pharmacist Verifies the Prescription (2nd Check)
In step #4, the pharmacist completed the important clinical decision-making process to ensure that the prescription is accurate while also appropriate, safe, and effective for the patient.
Here, the pharmacist physically verifies that the labeled medicine is in fact filled for the correct medication, strength, and quantity.
Given the sheer number of prescriptions to be filled, it can be easy for a pharmacy colleague to accidentally mislabel a bottle or fill the wrong medicine/strength for a prescription. However, these errors are caught by the pharmacist prior to verifying and completing the order for the patient.
When an error is caught by the pharmacist, the prescription is sent back to the filling station and the error is corrected by the technician or intern that is assigned to fill prescriptions.
7. Prescription Given to the Patient
Once the prescription(s) are filled, then the medicine can be given to the patient. Patients can obtain their medicine via in-person pickup, drive-thru, and/or delivery depending on the pharmacy. This is the easiest and quickest step of the process.
This step is typically only slowed down if the patient requests for a prescription to be rebilled to a different insurance plan or alternative discount card from what was originally billed during step #3. If this is the case, then steps #3 through #6 must be repeated by the pharmacy.
All of this occurs while concurrently answering a horde of unrelated phone calls, attending to patients at the counter, answering many off-the-wall questions, and completing other required pharmacy tasks. However, this simply adds to the fun and controlled chaos of the community-based pharmacy.
Reference:
1. James P. Amerine, Pharm.D, Tippu Khan, Pharm.D., M.H.A, Brett Crisp, Pharm.D., M.S, Improvement of patient wait times in an outpatient pharmacy, American Journal of Health-System Pharmacy, Volume 74, Issue 13, 1 July 2017, Pages 958–961, https://doi.org/10.2146/ajhp160843
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