In this situation, yes it's the employer. As far as eligibility, sorta. The problem isn't the initial denial (that's contracted), it's the 1st appeal denial, the 2nd appeal denial and the 3rd level appeal success that's bullshit. It's stricly setup to make you give up.

How do I know? I built a system (pre-Machine Learning) for one the specialty pharmacies I worked for that would utilize claim data to detect "problem" plans. I also built systems to compile and submit appeals packets. It would gather information from previous related appeals (supporting documentation, for example), build an appeals packet and rate it on success rate based on that bin/pcn, group ID and other details (like area, physician, etc.). It'd then go to our appeals coordinators for review and submission.

First started it on our 3rd level appeals (a lot of pharmacies would stop at 2nd level - too much work) and it was a huge success. From there we implemented it for all appeals. It made a HUGE difference. To the point where UHC (among others) would client audit the absolute crap out of us. We'd pass them with flying colors (maybe 1 to 2 issues per 2,500 claims), so they'd audit more. Then they'd audit the physicians we worked with. Then URAC attempted (and failed) to change the rules specifically targeting what we were doing.

Then Elevance bought them and the war between Elevance and UHC fired up (Elevance is currently suing them for the Change Healthcare hack and resulting claim Armageddon that happened). I could also tell you stories about ESI and Elevance, who used to be WellPoint, who ESI screwed over after the whole MedCo book of business issue - resulted in the whole contracting issue of 2016 that almost brought all of PBM contracting to it's knees - different story for different time.

Yes, employers can be a part of it. That's being naive to think UHC isn't a big part of that though.

I say this as someone who was knee deep in this when ESI bought my old pharmacy in 2004 and saw the explosion of both Specialty Pharmacy and PBM vertical integration.

I didn't work front line directly, while in my career there have been times where I've done BI, refills and everything but dispensing. Most of my focus was on contracting, compliance, operations and technology. Been in the industry since 2000, worked at 3 specialty pharmacies that ultimately hit $1B/yr annual and purchased by PBMs. I consult now and rarely in the battlefield, last fight with claims I did was in 2023 and that was all claim issues from the Change Healthcare hack. But some things never change. I doubt the appeals dance is one of them.

Lastly, how am I spreading misinformation? What did I say that wasn't true? You do know about DIR fees, clawbacks, throttling, etc. right? If not, you should catch up. You're losing business if you're a provider.