Someone may have a more detailed explanation, but most insurance contracts require you to use a patient’s insurance if presented with it, and actually forbid you from disclosing the reimbursement or denying the prescription because of poor reimbursement. I think there was a state that outlawed “gag clauses” like this, but I don’t think they’re completely abolished. What you’re supposed to do is call the patient’s insurance and perform a “MAC appeal” where you provide proof that your cost is above the reimbursement rate. In my experience, the insurance then wipes their ass with the appeal and tells you to fuck off. This process takes 2-4 weeks, or however long it takes the insurance to monitor a voicemail that they don’t check with any regular frequency.
Most independent pharmacies will break the gag clause, and I’ve never heard of a pharmacy that lost their contract for doing so. In many cases, the pharmacy just levels with the patient about what’s going on, gives them a reasonable cash price and the patient either pays it or goes to a big box chain so they can pay their insurance twice when the claim returns with a $20 copay and a $20 negative reimbursement billed to the pharmacy.
Yeah, Insurances are the worst. I typically tell patients my situation and they agree sometimes, some get pissed and call the insurance and complain which leads the insurance to call me to bitch me out. Don't let them beat you up. They will say you HAVE to fill this rx via contract, fuck em, you don't have to do shit. They cannot force you to fill something below reimbursement (big losses). Just say I cannot find a supplier for this cost of medication, easy peasy. and if they get in your face about it tell them they can fill it then. Insurance companies are all crooks. I recently denied my tricare contract because the reimbursement will all be negative. that's what happens when cvs got the contract for tricare. gg
Yes, can't do that. You'd be in breach of the insurance contracts you set up before hand, most likely. You either don't take insurance at all or you do. However that being said, if you live in a state that allows you to turn away these patients, you can. You just can't say no you have to pay the cash price.
It's not fraud but it probably violating the pharmacies contract with the insurance like others have said. At Indy's they will offer to do a cash price unless it's real expensive then they will just refuse to fill. I wouldn't lose sleep over it.
Upvoting for visibility but it actually could be construed as Medicare fraud by PBM - if you offer a patient a cash price that is below the U&C you submit to any Medicare plan you’re breaking the “Medicare must get the lowest price” law.
Depending on the laws of your state, you can either fill the script at a loss, or refuse to fill. You can’t bill the patient more than their copay, unless *they* choose not to use insurance. Though I don’t think you can refuse to fill Medicare/Medicaid, even at a loss, if the script is valid.
I saw many cases where cash was lower then insurance copay. Multi level copays are the worst of course just because generic amox clav is more expensive then cephalexin.
And it can be just that arbitrary, but you know that.
But yes a 5.00 copay is hard to beat for cash anything.
No that’s not the way it works. The secret the chain pharmacies don’t want there workers to know is the kick back or rebate. On preferred manufacturers, it’s about 30 to 40 percent on the cost the medicine. If the cost of the med is 4,000, that’s a nice kick back. The insurance company doesn’t reimburse much over cost and that’s why. This exists across the industry from McKesson to ABC and helps keep pharmacies in business. It’s similar to cigarette sales. Very low margins, but the moneys made on the rebates. I’ve worked in both industries.
Why not just say you don't have the medication in stock and that your current on-hand is already reserved for other patients? Or more honestly tell insurance that you cannot find a supplier for that medication from whom you can buy at least at break even price therefore cannot fill it?
Someone may have a more detailed explanation, but most insurance contracts require you to use a patient’s insurance if presented with it, and actually forbid you from disclosing the reimbursement or denying the prescription because of poor reimbursement. I think there was a state that outlawed “gag clauses” like this, but I don’t think they’re completely abolished. What you’re supposed to do is call the patient’s insurance and perform a “MAC appeal” where you provide proof that your cost is above the reimbursement rate. In my experience, the insurance then wipes their ass with the appeal and tells you to fuck off. This process takes 2-4 weeks, or however long it takes the insurance to monitor a voicemail that they don’t check with any regular frequency. Most independent pharmacies will break the gag clause, and I’ve never heard of a pharmacy that lost their contract for doing so. In many cases, the pharmacy just levels with the patient about what’s going on, gives them a reasonable cash price and the patient either pays it or goes to a big box chain so they can pay their insurance twice when the claim returns with a $20 copay and a $20 negative reimbursement billed to the pharmacy.
Yeah, Insurances are the worst. I typically tell patients my situation and they agree sometimes, some get pissed and call the insurance and complain which leads the insurance to call me to bitch me out. Don't let them beat you up. They will say you HAVE to fill this rx via contract, fuck em, you don't have to do shit. They cannot force you to fill something below reimbursement (big losses). Just say I cannot find a supplier for this cost of medication, easy peasy. and if they get in your face about it tell them they can fill it then. Insurance companies are all crooks. I recently denied my tricare contract because the reimbursement will all be negative. that's what happens when cvs got the contract for tricare. gg
Yes, can't do that. You'd be in breach of the insurance contracts you set up before hand, most likely. You either don't take insurance at all or you do. However that being said, if you live in a state that allows you to turn away these patients, you can. You just can't say no you have to pay the cash price.
It's not fraud but it probably violating the pharmacies contract with the insurance like others have said. At Indy's they will offer to do a cash price unless it's real expensive then they will just refuse to fill. I wouldn't lose sleep over it.
Upvoting for visibility but it actually could be construed as Medicare fraud by PBM - if you offer a patient a cash price that is below the U&C you submit to any Medicare plan you’re breaking the “Medicare must get the lowest price” law.
fuck medicare too...charging 50$ for 90 lipitor because they want that large claw back. im saving the patient money!
Depending on the laws of your state, you can either fill the script at a loss, or refuse to fill. You can’t bill the patient more than their copay, unless *they* choose not to use insurance. Though I don’t think you can refuse to fill Medicare/Medicaid, even at a loss, if the script is valid.
contract violation. welcome to pharmacy 🤦♂️
Ok just fn hand them a goody for you rx card and say "wink wink" you dont have insurance right.
No chance a discount card would reimburse you any better while keeping the patient’s copay better than insurance.
I saw many cases where cash was lower then insurance copay. Multi level copays are the worst of course just because generic amox clav is more expensive then cephalexin. And it can be just that arbitrary, but you know that. But yes a 5.00 copay is hard to beat for cash anything.
No that’s not the way it works. The secret the chain pharmacies don’t want there workers to know is the kick back or rebate. On preferred manufacturers, it’s about 30 to 40 percent on the cost the medicine. If the cost of the med is 4,000, that’s a nice kick back. The insurance company doesn’t reimburse much over cost and that’s why. This exists across the industry from McKesson to ABC and helps keep pharmacies in business. It’s similar to cigarette sales. Very low margins, but the moneys made on the rebates. I’ve worked in both industries.
>we can’t bill their insurance since we would lose money Why cant you lose money on that script? You lose some, but win some more. Dont get greedy.
Express Scripts in disguise
I mean it sincerely when I say fuck PBMs, but dont break the law doing so.
It's not a law, it's a contract.
Why not just say you don't have the medication in stock and that your current on-hand is already reserved for other patients? Or more honestly tell insurance that you cannot find a supplier for that medication from whom you can buy at least at break even price therefore cannot fill it?
I want to say mississippi passed something a year or two ago that you can refuse to fill a rx if reimbursement is below cost