Software glitch brings down drug plan claim processing

Canadian pharmacists were unable to process plan member claims from several insurers, including Manulife Financial, for several days after a third party provider experienced a systems outage late last week.

Mississauga, Ont.-based ESI Canada, which Manulife and other insurance companies use to view and process claims at pharmacies, said the outage followed the implementation of a quarterly server release update. Company president Jean Joubert said ESI chose to shut down the system after the problem was discovered Friday morning to maintain the data integrity of its clients’ transactions.

“By yesterday (Monday) afternoon we were back on to re-open the gates to transactions,” said Joubert in an interview with ITBusiness.ca Tuesday. “It’s a very complex system, which involves individuals’ information. We had to be very careful to take all the necessary precautions before restarting the system.”

Joubert added the problem, which he refused to specify, was identified and corrected on the weekend, but ESI didn’t want to reboot the system until it was sure the data was secure.

“It’s something that happened in production that didn’t show up in tests that created a problem and we had to take it off to protect the integrity,” said Joubert.

He also wouldn’t comment on whether other insurance companies were affected but, when pressed, confirmed that Indian and Northern Affairs Canada is a client of ESI.

Manulife Tuesday posted an update on its Web site under the group benefits section informing customers that “the issue with ESI Canada has been resolved and pharmacists are now able to process plan member claims using the pay-direct system.”

In an interview Tuesday, Manulife said the outage affected plan members with drug cards across Canada.

Manulife Canada spokesperson Tom Nunn said when something goes wrong with new technologies like the pay direct system, people notice it instantly.

“In the previous world where you would submit a claim you wouldn’t necessarily see if there was an issue there,” said Nunn. “Whereas now if the card doesn’t work when you’re at the counter you see it right away.”

In addition to the Web site, members were made aware of the problem through their employer and given three options, said Nunn. In an internal memo obtained by ITBusiness.ca, plan members could pay for the drug and submit a claim for reimbursement; wait until the issue with ESI had been resolved to make their purchase; or the pharmacists may choose to provide the member with the drug and submit the claim to ESI when the issue has been resolved.

“We were just making sure that clients themselves knew what to do so they weren’t worried about it,” said Nunn. “We knew it would be resolved fairly quickly. We just wanted to make sure no one was feeling like they weren’t having their claims processed.”

Both Manulife and ESI said they notified pharmacists of the problem through e-mail and fax.

Brian Stowe, pharmacist at The Prescription Shop at Carleton University in Ottawa and president elect of the Canadian Pharmacists Association (CPhA), said while he received faxes from ESI to say the problem is fixed, he still had patients he was unable to bill on Tuesday.

“It keeps going back and forth,” said Stowe. “Generally I tell my staff to keep trying and it eventually goes through.”

Joubert said ESI is currently putting through claims at a high rate — ESI processes 50 million transactions annually — without blackouts or delays.

“As far as I’m concerned we’re ending our claims process with a normal number of rejects,” said Joubert. “Rejects are normal because of elegibility issues or data issues. I’m surprised to hear that.”

Stowe said issues like this one are tough for pharmacists because of their professional responsibility to the patient as a health-care provider.

“If it’s their insulin and it’s a $60 script and they don’t have the money, that’s where it really gets challenging for us,” said Stowe. “If it’s their heart medication we can give them a couple of days’ worth and tell them to come back and hopefully things will sort their way out and we’ll bill it through at that point.”

In the first case, for example, Stowe said if the patient regularly comes to the pharmacy and their prescriptions are normally approved, he would give it to the patient and bill the insurance company later. If it’s a new patient, however, Stowe said he would likely have them pay upfront and submit a claim.

“A lot of times patients think they’re covered but they’re not or they think they have online coverage but they don’t,” said Stowe, “We don’t have a way to confirm that. When the system’s down we’re not likely to start phoning on every patient because wait times can be pretty horrendous at times.”

In cases like this, Stowe said he usually notices something’s wrong within 15 minutes to an hour. While he sometimes contacts the software provider to report the problem, often times (as with ESI) he opts not to because of long phone queues or difficulty getting through.

“It would be nice if there was a Web site that posted who’s down on any given day.”

Comment: info@itbusiness.ca

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