I received a email from a pt after the pt got questioned by their prescriber after running a PMP report on the pt. After the pt did some investigation, it would seem that the Pharmacist first filled the controlled Rx and decided that it was not enough money from the insurance company and reversed the claim and told the pt that the insurance wouldn’t pay for the Rx, but he could fill it for cash… which the pt agreed… and the Pharmacist re-ran the Rx thru their computer system as a cash Rx… which in turned a SECOND submission to the state’s PMP database… showing that the pt got TWICE the doses that the prescriber wrote for… one being billed to the insurance and a second one for cash.
Unfortunately, everyone believes that these PMP are INFALLIBLE and could be so far from the truth. With fake driver licenses being presented and Pharmacists deciding after the Rx has been processed by a technician that he/she is not going to fill it…. for whatever reason.
This patient has contacted his/her insurance company and verified that the claim was submitted and reversed and has talked to the pharmacy – not the Pharmacist that processed the Rx – and was told that the Pharmacist reversed the claim because he didn’t think that he was being paid enough.
The representative from the pt’s insurance company suggested that the pt contact their fraud/abuse dept and file a complaint.
The potentially larger issue is what liability to pharmacists/pharmacies that do such things including auto refills that are not picked up and returned to stock… when another healthcare professionals run a PMP reports and refuse service or discharge them from a practice because of these erroneous entries in the PMP database. Because it is unlikely that anyone is going to make phone calls to confirm/deny what the PMP reports.
Filed under: General Problems
it seems that the other issue here is that the Rx was posted to the PDMP twice. This has happened in our pharmacy,too. Pt presented an RX on Saturday but insurance would not pay until Monday. At first, pt said “going out of town and I will pay cash” until he was informed of the price. RX was billed, filled and picked up on the following Monday. Since PDMP info is gathered weekly, the prescription did show up on the database twice.
I thought that insurance companies have pre-negociated prices that they pay? Isn’t that why they give us a list of Pharmacy’s with co-pay amounts. Sounds to me like this pharmacist needs to be reprimanded and fined, if not fired.
Another bad guy puts his/her name on the pain patient’s list…even if it wasn’t a controlled substance!
I’m not sure I see what is wrong with that scenario. Insurances are limiting the amount of narcotic medication they will pay for. So if I had a prescription for 200 tablets and my insurance only covers 100 tablets I would pay for cash for the other hundred that were not covered by insurance. So again, as long as her doctor wrote her for 200 total it would not be any crime to pay cash for the amount your insurance does not cover.
The Pharmacist LIED to the pt about the insurance paying for the medication. the insurance would not pay ENOUGH $$$ for the quantity prescribed.. would pay the pharmacy abt $60 and he charged the pt $110 for the Rx and didn’t bill the insurance company the first penny. Pharmacies have contract with insurance companies that they are not allowed to bill the pt for any more than what the insurance will allow when the insurance is billed and they must bill the insurance if they are in the insurance company’s pharmacy network. It is a form of insurance fraud
The other issue in addition to what Steve replied with is that this then appears as being filled twice on your prescription report. Which is grounds for immediate dismissal from a pain management doctor as it would violate the contract that most doctors now have you sign and adhere to. Its not that your insurance only pays so much and you pay the rest out of pocket. Its that the pharmacist already ran the prescription through as an insurance claim, decided it wasn’t what they felt was enough money, and then told the patient they could pay for it out of pocket instead. So you’d have one fill register on your report from the pharmacy running it through your insurance and then the second (for the same script) from where you then paid out of pocket for the entire script. Thus resulting in two hits on your report which is run by virtually any doctor you see at any time. But the medication was actually only filled one time. These reports are being treated like they are the end all of factual information. A discrepancy like that can cause a world of hurt for the patient who is innocent in the matter. Hope that makes sense.