Over the counter quandry

[Guest lschaab]

Let me preface: This is not a joke. If a receipt for K-Y Jelly has a handwritten note that says 'itching', should we accept it? The provider, date of service, product name and amount are all clear. Is everyone asking for physician notes on questionable calls, or taking a participant statement self-diagnosing the reason for purchase?

Just curious.....

[Guest JerseyGirl]

This is a situation where I feel you would definitely want some additional documentation provided by the participant’s physician. The product in question could be considered for personal rather medicinal use, and the term *itching* is not exactly what I would think of as a valid diagnosis. When it comes to claims adjudication, especially of OTC items, I think it is best if we err on the side of caution.

[Guest lschaab]

We are trying to determine if a self-diagnosis as the rational (or reason) for purchasing a particular item is adequate validation to reimburse OTC's. To err on side of caution means that any questionable item must be accompanied by a physicians recommendation rather than a participants claim that a particular item (whether for personal use or not) alleviates a self-diagnosed ailment - correct?

[Guest BeneGal]

If your main goal is to prevent "self-diagnosis" and require a physicians recommendation for everything - I think you might be making it much harder on yourself than need be.

Example: If I have a head cold and I go buy some Advil Cold & Sinus medicine. I'm pretty sure of my self-diagnosis "head cold" but your method forces me to go to my doctor pay a copay/deductible just to have him tell me I have a cold and then "recommend" some OTC product.

Am I understanding you correctly???

And FYI - K-Y Jelly is NOT for itching - it is a lubricant period and has no medicinal purpose. I would think it would be denied...

A post a while ago from someone said that when it came to OTC products (not band-aids or gauze etc...) they were going to concentrate on the word "medicine" or "medicated" in the product for it to be valid.

[Guest MSMA]

Not to drag this out further than necessary...but hopefully it will actually make a point about how are WE NON-MEDICAL claims adjusters supposed to determine use of every OTC item ???

KY is a perfect example. I think most people assume it's lubricant qualities are for normal {ahem} activities...BUT, it is also used to treat a painful chronic medical condition that is most often seen when women reach a certain age...

Personally, I don't want to have to ask....and I'm not sure we can assume it's use either.

I really wish this whole OTC had never happened. What a headache.

Because of this, we are limiting our participants to those very specific items mentioned in the IRS ruling. We're still hammering out the quantity issue though...

[Guest lschaab]

BeneGal, I agree, I think we are putting too much pressure on ourselves if we request a doctors note/recommendation for every questionable claim, but where is the line to be drawn? For example, we received a claim today for eye drops, which we would reject because it is for personal use, unless they can produce a note. For the Listerine we received an employees notation "gingivitis", do we take their word (self diagnosis) or request the note. Its personal use, but if they have the condition - gingivitis - the purchase should be allowable.

I hate this too, and my claims department hates me (however misdirected that may sound)! :angry:

[Ron Snyder]

I presume that you know the claims department hates you because they make you go through such claims adjudications on OTC items!