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View Full Version : OT - Pharmacy/prescription ?


adventure_woman
03-27-2011, 02:13 PM
Sort of OT...but it is slightly budget related!

DH takes a drug for his migraines. He has gone through all the hoops with our insurance company and they have him pre-authorized to get 45 pills for a 3mth period. This means we only pay 2 copays instead of 3...saving us money. We have had it filled just fine at the pharmacy last year (prescription expires 6/11)

Now the pharmacy is telling us that their 'auditor' needs a note from the dr. stating how many migraines he gets in a month in order to fill the prescription. What? IMO...what business is it of the pharmacy to even ask what the drug is for...much less how many migraines he gets in a month? He has a valid prescrip and we know the insurance will pay for it! (we already checked w/the insurance, and they are not the issue)

I am going to speak to a mgr tomorrow but wanted to get anyone's take on this? It wouldn't matter...except they goofed up billing last month...and long story short I still want them to bill for the 2 mths they shorted us so we only have to pay 1 copay. I am already half-planning on going to a different pharmacy after this....this is ridiculous....

jgates
03-27-2011, 02:19 PM
I will be honest & say that is the first time I have ever heard of anything like that.

I have experienced issues with my insulin when the bottles were not 'holding up'. The doctor increased the number of bottles I could get per month so I always had fresh ones, but the insurance/pharmacy still wouldn't fill the extras. The # of units per day the doctor had written down at one time (which was no longer accurate) was still in the computer - so it looked like I was getting way more than I needed. However that was all logical mathematics. And it was from a number the doctor recorded, not them asking me at the pharmacy how many time as day I was taking a shot.

Will they refuse to fill it if you say you feel it is violating his privacy to ask that question?

If nothing else, change pharmacies for all prescriptions or see if the insurance company has their own mail order provision where you normally can get 3 months shipped to you at a time for a single co-pay. Many insurance companies offer this type of affiliated arrangement.

ajh88
03-27-2011, 05:07 PM
Now the pharmacy is telling us that their 'auditor' needs a note from the dr. stating how many migraines he gets in a month in order to fill the prescription. What? IMO...what business is it of the pharmacy to even ask what the drug is for...much less how many migraines he gets in a month? He has a valid prescrip and we know the insurance will pay for it! (we already checked w/the insurance, and they are not the issue)

I am going to speak to a mgr tomorrow but wanted to get anyone's take on this? It wouldn't matter...except they goofed up billing last month...and long story short I still want them to bill for the 2 mths they shorted us so we only have to pay 1 copay. I am already half-planning on going to a different pharmacy after this....this is ridiculous....

I'll give you my take since you asked...

First, IMHO, the pharmacy actually DOES have the right to ask how many migraines he gets a month. They have to bill the insurance company accurately - so if 45 pills are a 3 month supply, they must bill it as such. They likely (as in probably over 99%) know or have a strong indication of WHY he is getting the medication simply based on what the medication is, KWIM? I guess from my perspective, your pharmacy (and pharmacist) are a part of your health care team...they work with your doctor on a regular basis (or at least they *should* be doing so). Would you ever refuse to tell your DH's doctor how many migraines your husband gets? And along the same lines, you don't have a problem posting your DH's health issue on a public message forum, but you are offended your pharmacy asked you for additional information about it?

Second, the pharmacy probably DID have an internal audit regarding insurance billing. A small independent pharmacy where I rotated last year was audited while I was there. You would be surprised at the reasons why insurance companies will take back money they've already paid - things like a time not being written on an Rx. Billing for correct days' supply and with correct directions are HUGE audit risks and flags. Over a year ago it became unacceptable to simply have "Use as directed" for prescriptions, specifically because of insurance billing. As the PP illustrated with their insulin example...insulin and medications that you don't need to use every day (such as migraine pills) really get targeted by auditors - partly because they know that oversights occur on these Rx's and partly because they are expensive drugs.

Finally, I guess I don't understand what happened with the billing. You got a 1 month supply and paid 1 co-pay? But you should be able to get a 3 month supply for 2 co-pays? I don't want to speculate on what may have happened on the billing end because I don't think I have the whole picture. As for the "note" from the doctor - the pharmacy should be able to get that on their end without you worrying about it (via fax or phone if it is acceptable in the state where you live). I can ask a patient how many migraines they get (or how often they use their medication) or how much insulin they use...but at the end of the day, I have to have verification from the physician to document in our records for auditing purposes.

Trust me, pharmacies do not enjoy dealing with these (insurance) issues any more than you, the customer, does. I next to guarantee that they are not singling you out to give you a hard time about this and it is probably nearly as frustrating for them as it is for you. However, as I tell everyone who asks, if you aren't happy with the service you get at your pharmacy, you should switch. Good luck in getting things resolved.

simonsmom
03-27-2011, 07:08 PM
as a pharmacist I have to say OP really ticked me off. what business is it of the pharmacist? really? we are not glorified cashiers! we do so much that you don't even realize, like call doctors and correct their mistakes,all without your knowing-because we wouldn't want to tell you that your doctor screwed up. I probably save a life a day. and yes we get audited by insurance companies all the time! one little clerical mistake on a rx with 11 refills and they take back all the money from all 12 fills. It puts small pharmacies out of business. If your pharmacy made a billing error it's hard to believe they wouldn't fix it. we try to fill a prescription for the way a doctor writes it. many times the doctor writes for a 30 day supply automatically. if your insurance allows a 90 day supply and your MD writes for a 30 day-guess what-we can only fill a 30 day supply. so assuming your MD wrote for the days supply you wanted my guess would be that the insurance company made them cut it back. Some insurance plans pay for a 90 day supply only at certain pharmacies or mail order. Also some drugs are limited in how many you can get to due to their price.Don't be so quick to blame the pharmacist. you see any one else in the healthcare field that is so easily accessible and gives FREE medical advice?

teacup princess
03-27-2011, 08:09 PM
Yep. This most likely is due to an audit by YOUR insurance company who is trying to deny reimbursing the pharmacy due to a technicality like the days supply of the medication (which for migraine medicine is how many migraines your husband gets per month). Seriously, are the pharmacists mind readers? How would they know how to bill the days supply of the migraine medicine (ie: how many migraines your husband gets per month) if they didn't ask? How would you like to sell your goods and services only to have a third party pull their payment back due to some no-nonsense technicality? And by the way, did you know you can get 5 different answers from 5 different insurance reps when you call them on the phone to ask a question about insurance benefits? I can't tell you the number of times I've called some insurance billing rep who've had no clue about why a claim wasn't going thru, only to call back 5 seconds later, get a different person on the other end of the line and finally get an answer to my billing question. Perhaps if you don't like the way the pharmacy is billing your medication you should start submitting your own claim forms to the insurance company, wait the 3-5 months it takes to get re-imbursement (IF they decide you've filled out the form right), and find out for yourself what a pain in the butt it is to deal with insurance billing.

simonsmom
03-27-2011, 09:00 PM
would also like to add that when pharmacies are audited and they find something incorrect- the insurance company not only takes back the dispensing fee they paid but also the actual cost of the drug that was dispensed. We had one recently that would have cost us $12,000 if we hadn't been able to prove we were correct.

adventure_woman
03-27-2011, 10:18 PM
I didn't mean to offend any pharmacists or anything here...I recognize the training and education you have to go through. I was/am really frustrated because we have been receiving the prescription fine for the last 6 months. It took my DH months of working with the insurance co and his dr. to have them allow for the medicine. I just didn't/and don't understand what happened all of a sudden to make the pharmacy want more information on his prescription that he already has (and has been filled for the last 6+mths). The problem they said was with the pharmacy auditor...not the pharmacists (which in my mind are 2 different people...maybe not I have no idea) or the insurance co. I had never heard of an auditor, which is why I posted here asking about it....I had no other place to ask and I was trying to get information before I asked the pharmacy mgr about it.

(The billing is a long story...but they inaccurately billed for 58 days instead of 90 days, which means the insurance co. only let one month go through. Per insurance co (and pharmacy), had they billed for 90 days it would have gone through for the 3mth supply). They billed for 58 days due to a computer glich that they didn't fix before it went through...)

ajh88
03-27-2011, 11:30 PM
Based on what you've said about the billing, I would think they should just be able to re-bill the insurance for that fill and get everything straightened out for you. The auditor could have been someone from the insurance company or it could have been an internal auditor from the pharmacy (depends on how big or small of a pharmacy you deal with) - though likely it was NOT the pharmacist. Either way, they may need some additional information from your DH's physician. Again, they (the pharmacy) *should* be able to take care of that on their end - although sometimes it moves a little faster when the patient contacts their doctor's office to let them know the situation.

ETA: Large companies have internal auditors who routinely review prescriptions for errors/omisions/etc. that could cause essentially "chargebacks" from the insurance company. As simonsmom described, insurance companies will find nearly any reason at all to take back money they have paid (sometimes many months or a year after the fact)...so these auditors try to prevent that from happening. It is much better for the pharmacy if they have an internal auditor catch things BEFORE an insurance company audit occurs. If the insurance auditor catches something, it is likely the pharmacy will be paying back tens of thousands of dollars (I believe the pharmacy where I rotated had to pay back over $100,000! They weren't committing fraud, just not following every tiny rule of the insurance company - many of which are NOT state or federally mandated laws but rather put in place by the company and IMHO for the sole purpose of recouping money from pharmacies). And it seems like every insurance company has their own little set of rules...but I digress. Just thought I would give you some info on why there are auditors. :)

It is possible it was filled with no problems before, but then the auditor has found it and questioned it in between your last fill and this one...hence the issues now. Also, if this was your first fill of 2011, it is possible that updates on either end (pharmacy or insurance) caused some glitches. I know the only time we go changing days' supplies on refills is when there are insurance rejections or other issues of that sort (like we realize we have billed incorrectly previously).

Hopefully it goes smoothly for you - I really do understand how frustrating it can be (on both sides of the counter!).

adventure_woman
03-28-2011, 08:08 AM
Based on what you've said about the billing, I would think they should just be able to re-bill the insurance for that fill and get everything straightened out for you. The auditor could have been someone from the insurance company or it could have been an internal auditor from the pharmacy (depends on how big or small of a pharmacy you deal with) - though likely it was NOT the pharmacist. Either way, they may need some additional information from your DH's physician. Again, they (the pharmacy) *should* be able to take care of that on their end - although sometimes it moves a little faster when the patient contacts their doctor's office to let them know the situation.

ETA: Large companies have internal auditors who routinely review prescriptions for errors/omisions/etc. that could cause essentially "chargebacks" from the insurance company. As simonsmom described, insurance companies will find nearly any reason at all to take back money they have paid (sometimes many months or a year after the fact)...so these auditors try to prevent that from happening. It is much better for the pharmacy if they have an internal auditor catch things BEFORE an insurance company audit occurs. If the insurance auditor catches something, it is likely the pharmacy will be paying back tens of thousands of dollars (I believe the pharmacy where I rotated had to pay back over $100,000! They weren't committing fraud, just not following every tiny rule of the insurance company - many of which are NOT state or federally mandated laws but rather put in place by the company and IMHO for the sole purpose of recouping money from pharmacies). And it seems like every insurance company has their own little set of rules...but I digress. Just thought I would give you some info on why there are auditors. :)

It is possible it was filled with no problems before, but then the auditor has found it and questioned it in between your last fill and this one...hence the issues now. Also, if this was your first fill of 2011, it is possible that updates on either end (pharmacy or insurance) caused some glitches. I know the only time we go changing days' supplies on refills is when there are insurance rejections or other issues of that sort (like we realize we have billed incorrectly previously).

Hopefully it goes smoothly for you - I really do understand how frustrating it can be (on both sides of the counter!).

Thank you for explaining this to me. Like I said (or was trying to say anyway..), I had no idea how phamacies work, and I was just looking for more information so I can understand better where the pharmacy is coming from before I talk to mgr today. To have an idea of what they are talking about helps me!

andymattmom
03-28-2011, 09:30 AM
as a pharmacist I have to say OP really ticked me off. what business is it of the pharmacist? really? we are not glorified cashiers! we do so much that you don't even realize, like call doctors and correct their mistakes,all without your knowing-because we wouldn't want to tell you that your doctor screwed up. I probably save a life a day. and yes we get audited by insurance companies all the time! one little clerical mistake on a rx with 11 refills and they take back all the money from all 12 fills. It puts small pharmacies out of business. If your pharmacy made a billing error it's hard to believe they wouldn't fix it. we try to fill a prescription for the way a doctor writes it. many times the doctor writes for a 30 day supply automatically. if your insurance allows a 90 day supply and your MD writes for a 30 day-guess what-we can only fill a 30 day supply. so assuming your MD wrote for the days supply you wanted my guess would be that the insurance company made them cut it back. Some insurance plans pay for a 90 day supply only at certain pharmacies or mail order. Also some drugs are limited in how many you can get to due to their price.Don't be so quick to blame the pharmacist. you see any one else in the healthcare field that is so easily accessible and gives FREE medical advice?

:thumbsup2:thumbsup2:thumbsup2
You pharmacists are truly appreciated. Know all the hard work you do! Also know that you can give assistance on prescriptions and have caught mistakes in our family that doctor made. My son wants to go to pharmacy school ---know how hard that is and how much you have to know.

rxpert86
03-28-2011, 10:24 AM
I just have to reply to this post adventure woman. I am a pharmacist and run into this issue a lot. The insurance companies regularly audit high dollar prescriptions, (even those with prior approvals) looking for ways to avoid paying the claims. One thing they do is to require proof of need. This means we have to call people who get a lot of diabetic test strips and have them give us a copy of their blood sugar testing logs, proving they are actually using so many strips. Another one is to request documentation of migraine frequency. Just a few months ago we were charged back over $2500 for a maxalt prescription. This means even though the insurance had approved the claim and paid the pharmacy for the claim they took back the money and said they had to have proof that the patient had that many headaches per month. We had to have a letter from the doctor and patient which verified that the patient actually had that many headaches. This is AFTER the claim is approved and paid. In fact almost a year later during an audit. Audits routinely cost us $6000-$10,000 dollars and we adjudicate every claim at time or service so this means the insurance has said it will pay before the patient ever leaves the store!

It's absurd sounding, I know, but we can't afford to just write off that much money. Please don't blame your pharmacy for this. It is extra work for us and winds up costing everyone money. Believe me we do not personally care how many headaches our patients have, we have a lot more to worry about than to just be nosy about something like that!

Hope you enjoy your disney cruise!

adventure_woman
03-28-2011, 10:33 AM
I just have to reply to this post adventure woman. I am a pharmacist and run into this issue a lot. The insurance companies regularly audit high dollar prescriptions, (even those with prior approvals) looking for ways to avoid paying the claims. One thing they do is to require proof of need. This means we have to call people who get a lot of diabetic test strips and have them give us a copy of their blood sugar testing logs, proving they are actually using so many strips. Another one is to request documentation of migraine frequency. Just a few months ago we were charged back over $2500 for a maxalt prescription. This means even though the insurance had approved the claim and paid the pharmacy for the claim they took back the money and said they had to have proof that the patient had that many headaches per month. We had to have a letter from the doctor and patient which verified that the patient actually had that many headaches. This is AFTER the claim is approved and paid. In fact almost a year later during an audit. Audits routinely cost us $6000-$10,000 dollars and we adjudicate every claim at time or service so this means the insurance has said it will pay before the patient ever leaves the store!

It's absurd sounding, I know, but we can't afford to just write off that much money. Please don't blame your pharmacy for this. It is extra work for us and winds up costing everyone money. Believe me we do not personally care how many headaches our patients have, we have a lot more to worry about than to just be nosy about something like that!

Hope you enjoy your disney cruise!

I just talked to the pharmacy...and you were exactly right. I had no idea insurance companies did this (they try to scam everyone it seems!). I'm glad that I posted this on here...because then when I was talking to the mgr...I felt like I had some idea what he was talking about. Thank you all for enlightening me....again....I do have the upmost respect for you pharmacists....the person we were talking to yesterday just didn't explain it well...which led to me to be very confused and frustrated.

rxpert86
03-28-2011, 11:09 AM
simon's mom, I have been a pharmacist for 25 years. It a challenging but very rewarding career. There are many options and I have been involved in retail community pharmcy, drug research, and been the director of a hospital pharmacy. I have worked 50 hours/week and been on call and now job share a postition for 20 hours per week. I love what I do. Your son should be prepared to attend college for a minimum of seven years with lots of chemistry, anatomy, biology, and some math. It helps to have good people skills and be detail oriented. In my opinion, nothing in pharmacy school will be any harder than organic chemistry. If he does well in that course he will be just fine. My husband went back to college to become a pharmacist after getting a business degree. We have never regretted our decision.
Good Luck!

simonsmom
03-28-2011, 12:29 PM
simon's mom, I have been a pharmacist for 25 years. It a challenging but very rewarding career. There are many options and I have been involved in retail community pharmcy, drug research, and been the director of a hospital pharmacy. I have worked 50 hours/week and been on call and now job share a postition for 20 hours per week. I love what I do. Your son should be prepared to attend college for a minimum of seven years with lots of chemistry, anatomy, biology, and some math. It helps to have good people skills and be detail oriented. In my opinion, nothing in pharmacy school will be any harder than organic chemistry. If he does well in that course he will be just fine. My husband went back to college to become a pharmacist after getting a business degree. We have never regretted our decision.
Good Luck!

I think you mean andymattmom. I am a pharmacist. I have worked retail, nursing home care,and now we own an independant. I am also happy with my career choice (most days) ;)

ajh88
03-28-2011, 12:33 PM
To the OP - I'm glad you were able to talk about things with the manager *and* I'm glad that I, and others, could help enlighten you about some things. Before I went back to school, I was one of those people who got a little peeved (not angry) if my Rx wasn't done in 10-15 minutes. Boy, what an eye opener when I was on the other side!! I cringe to think that used to be my attitude! :flower3:

To the other RPh's...my graduation celebration trip is celebrating my graduation from pharmacy school. I'm done with my rotations, just studying for NAPLEX and getting ready to go back to work at my intern job. I'm so excited. Obviously (as you can see my age in my ticker), pharmacy is a 2nd career for me (when I first went to college, I got my bachelor's in biology but I *hated* chemistry - go figure!). I'm really looking forward to being done...it's been a long, hard road but so worth it!