Imagine a patient with rheumatoid arthritis calling her pharmacy liaison on Thursday. She usually receives a 30-day supply of her medication by mail. Her last shipment contained less. She has enough through Sunday.
The liaison checks the refill status and sends the coverage question to a patient support advocate. She tells the advocate when the patient needs her next dose. Monday.
The advocate calls the insurer. The representative says the mail-order pharmacy department did not approve a 30-day supply.
“What changed?” the advocate asks. “She was getting 30 days before.”
She asks to speak with the department the representative named. The call ends without an explanation, a transfer, or a callback time. When the liaison calls the patient back, the patient asks, “Will I have enough for Monday?”
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When I look at this case, I want to know when the rheumatology team learned a dose was at risk. The advocate was trying to find out why the usual supply had changed. The liaison knew when the patient would run out. The prescriber needed to hear about the risk while there was still time to respond.
What changed since the last refill?
The patient support advocate investigates the coverage barrier. The pharmacy liaison coordinates the refill and keeps the patient informed. When the insurer says “30 days wasn’t approved,” the advocate still needs to find out what was refused and who can address it. The liaison needs that answer to tell the patient what will happen next.
I would compare the last successful fill with the current one. What did the prescriber order? What did the pharmacy dispense? How many days did the claim say that quantity would last? If the claim shows a full month and the patient received less, her next refill could be rejected as too soon while she is already running out. The OptumRx pharmacy provider manual describes one circumstance that requires a correction. If a stock shortage leads to a partial fill and the pharmacy cannot supply the remainder within the specified period, the claim must reflect the amount actually dispensed.
A coverage limit on the quantity calls for a different response. Under Medicare Part D’s exception process, for example, the prescriber must provide a statement supporting an exception. A pharmacist’s clinical hold would call for a conversation about the reason for the hold. The answer the advocate received leaves all three possibilities open.
Who can act before the next dose?
Specialty pharmacy research gives us reason to take these handoffs seriously. In a Vanderbilt trial, pharmacists investigating missed doses identified workflow problems such as prescriptions routed to the wrong pharmacy and data-entry errors that delayed or prevented refill tasks. In a separate study of patients with rheumatoid arthritis taking tofacitinib, disease activity worsened during a planned two-week interruption. The effect of an interruption depends on the medication and the patient. The prescribing team needs time to assess that risk.
A pharmacist who would act on that information may never see the date the liaison recorded. An advocate who recognizes the urgency may still need the dispensing pharmacy to contact a claims help desk or the prescriber to support an exception. In a contracted specialty pharmacy arrangement, I would expect the operating agreement to specify how those teams reach one another, who alerts the prescribing team when a dose may be missed, and who confirms the alert was received. The liaison also needs to know when to update the patient, even if the refill is still unresolved.
What I would ask pharmacy leaders to review
I would review this case even if the patient received her medication on time. I’d want to know who first recognized that Monday’s dose was at risk, what they could see in the record, and whether anyone would have acted if the patient had never called back. The Agency for Healthcare Research and Quality recognizes near misses and unsafe conditions as opportunities to learn how to prevent harm. One case can show leaders where to look for a weakness they can correct.
I would ask the health system and its specialty pharmacy partner to sit down with a sample of shortened fills and rejected refills. Start with the date each patient needed the next dose and work backward. When did the advocate get a usable explanation? When did the prescriber learn about the risk? When did the liaison update the patient? Then confirm whether the patient received the medication in time and, where possible, ask whether any doses were missed. Record a clinician-directed hold, a confirmed access-related interruption, and an unknown outcome separately.
If the same problem recurs, each organization should name someone responsible for correcting it and set a date to review the next group of cases. I would measure whether prescribers learned sooner that a dose was at risk and whether fewer patients missed doses because a refill stalled.
On Monday morning, the record may show that the advocate called the insurer and the liaison called the patient. Where in that record would you look to find out whether she had a dose to take?
Tiffiny Black is an organizational governance and change strategist, scholar-practitioner, and author whose work examines how governance, organizational systems, policy, technology, and human behavior shape implementation and sustainable change. She holds a Doctor of Management with a specialization in organizational development and change.
Across more than eighteen years in health care, government, regulatory oversight, compliance, and organizational improvement, she has focused on the gap between institutional intent and what systems and people can sustain in practice. Her work spans organizational readiness, psychological transition, governance and accountability, health care systems, artificial intelligence and data governance, privacy and compliance, and the human consequences of organizational and technological change. She is the developer of Human Systems Readiness™, an emerging framework examining whether organizations and their people are structurally and psychologically prepared to absorb change.
Black is the author of Leader’s Edition: The Psychology of Change, Safety, Resistance, and Real Accountability and The Change They Didn’t See Coming: Why Psychological Transition (and Safety) Matter More Than Strategy, both published by Bold Moves Press. Her doctoral research at Colorado Technical University examined the psychological transitioning that leads to change resistance in law enforcement. Her writing on KevinMD addresses institutional trust and scientific dissent, clinician burnout and health care governance, psychological safety, payment integrity and fraud detection, and the difference between implementation and readiness. She shares updates on LinkedIn.
