PHARMACIST STEVE

Steve,

 

I recently started having trouble with the Wal-Mart Pharmacy .  My doctor prescribes a topical cream for dry skin (Clobetasol).  The pharmacy has been giving me this medication without incident for at least two years.  The last two times I attempted to refill my prescription the Wal-Mart employee behind the counter refused to refill my prescription until I provided several pieces of medical information: 1) Application area; 2) Amount being applied; 3) Size of the tube needed.  As aforementioned, it was a refill so they had that information.  As far as the other information is concerned, I refused to answer it and they refused to refill the prescription.  I walked out, called my doctor, and Wal-Mart Pharmacy left a message my prescription was ready.

 

I called Wal-Mart customer service and explained to them, in no uncertain terms, would I ever give my protected medical information to anybody at Wal-Mart outside of allergies and current medications I am taking.  They insisted they have a legal right to demand this information and will continue to refuse to refill my prescriptions unless I provide it.  They also intimated that insurance companies are insisting on my medical information due to a new policy that has taken effect in the last 6 months.  

 

I have taken your advice and contacted the Board of Pharmacy.  Before I submit my complaint, could you provide me with any references to the specific HIPAA law that protects the privacy of my medical information and which law that mandates a pharmacist can not refuse to fill a valid on-time prescription.

 

Thank you,

This is a educated guess… but.. it sounds like to me that your insurance and/or PBM (Prescription Benefit Manager) is demanding this. What I suspected that your PBM showed up at Wal-Mart one day to do a audit… and what I have heard that these PBM auditors show up expecting new data points that have never been looked for in previous audits.

These audits seem to get more and more draconian with each succeeding year…  They start out with supposedly selecting a “random” 1% of a pharmacy’s claim and then like with prescriptions like yours.. rejects the claims because certain “new data points” are not on the prescription… and there is no “making up the missing data points”… and then they reject the claim… and look at all the refills on that single prescription… take the $$ value of the Rx – including refills – and then when they are done with the audit they take the rejected claims and multiple the “amount due” by ONE HUNDRED .. because there was a 1% sampling… so the mistakes on that sampling must reflect all the mistakes that the pharmacy made on all the prescriptions billed to that PBM.  With three PBM’s controlling the vast majority of prescription claims.. and the PBM’s paid for some 80%-90% of all prescriptions… I have heard of some pharmacies get “audit recoup demands” of 10,000’s of dollars and the pharmacies are prohibited by their contract with the PBM to attempt to recoup any money from the pt for the rejected claim(s). With the average Rx price approaching $60 each.. it doesn’t take many clerical errors for a recoup demand to get to those $$$ figures.

And the contracts with the pharmacies are presented on a “take it or leave it” basis.. if you don’t take/sign the contract the PBM will make sure that your Rx patients will be sent to one of your competitors that has signed the contract.

5-6 years ago, Walgreens tried to negotiate with the PBM Medco – now part of Express Scripts – and refused to sign the contract offered.. because they felt that the reimbursement offered was TOO LOW & unprofitable…  Walgreen’s caved after about one year.. because they lost too much business.

And I would bet that Wal-Mart is prohibited by their contract with the PBM to charge you cash and let you file a claim with your insurance company.

The PBM industry is sort of like what we have heard about the Mafia and extorting money from retailers to allow them to stay in business… and it is all perfectly LEGAL… because the insurance industry is exempt from Sherman Antitrust Act by the McCarren Ferguson Act…  they can do things that are ILLEGAL in the rest of the business world …without consequences …

IMO, you can file complaints but your PBM is standing between you and you getting your prescriptions… with the demands for particular personal data points.

I just got a email from a pt on some eye drops and the PBM told the pt that he would have to get by with 4 bottles a month and I calculated that he would need – according to the directions – at least 7 bottles/month and that worked under the presumption that he “hit his eye” 100% of the time with each drop… which – IMO – will not happen in the real world …the pt’s doctor wrote for 10 bottles/month… which to me sounded like a reasonable number.  IMO.. the PBM was just “playing games”… hoping the pt would just accept their mandate… PBM’s and insurance companies are FOR PROFIT business and when it comes to a pt’s quality of life and their bottom line profit.. guess which one get their priority ?

Filed under: General Problems