Cash for controls?

[MARX22]

hey guys,

In my state we’re not required to check pmp as pharmacists although drs are. I still check to make sure pt isnt getting the same med filled twice in the same month. I never really focused on whether they got it from diff prescribers, different pharmacies, and different payment methods bc i was primarily focused on whether they are due or not. After all, what if they go to a clinic and see diff drs or a hospital. We cant control every aspect. I’m curious to hear how other rphs do it.

Also, if a patient wants to pay for a control with cash, I guess its okay if their insurance doesnt cover that med or if they once had insurance and now its expired. If they have insurance and it covers the control and they still want to buy it cash for whatever reason, that seems fishy to me but how can you refuse without endangering yourself? Or if they have no insurance would you refuse cash patients? Not sure how to go about it without pissing them off or having them slash my tires or wait to stab me lol

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[PA_dud3]

We do cash for controls quite often. We check the registry, though and of course prefer insurance. Honestly if you check the registry and don't see any real red flags there isn't much else you can do besides lie and/or not fill it.

 

[MARX22]

We do cash for controls quite often. We check the registry, though and of course prefer insurance. Honestly if you check the registry and don't see any real red flags there isn't much else you can do besides lie and/or not fill it.

if they dont have insurance then you fill with cash, but if they have insurance and it pays for it but they specifically ask you to do it on cash... do you guys do it?

also on pmp do you guys just check for whether theyre due or not or also focus on the other red flags like diff pharmacies/drs/payment methods?

 

[PA_dud3]

if they dont have insurance then you fill with cash, but if they have insurance and it pays for it but they specifically ask you to do it on cash... do you guys do it?

also on pmp do you guys just check for whether theyre due or not or also focus on the other red flags like diff pharmacies/drs/payment methods?

If they have insurance and the cash price is cheaper (it almost never is, but I've seen it on stuff like Pre-Op lorazepam) we usually do it like that. If insurance was cheaper and there's no P.A. issues but they insist on cash I don't think we would fill on cash. At least I've never witnessed it.

We check for due of course but yeah we also pay attention to whether the same meds are coming from diff clinics and pharmacies. Or if they get the same stuff from one pharmacy and something else from another pharmacy but only x med at x pharmacy and y med at y pharmacy, etc. if that makes any sense.

 

[MARX22]

How do you refuse without endangering yourself? I wouldnt want to fill if its covered with insurance and they insist on cash.

If they get one med from the same pharmacy all the time and another med from the other... do u just call md to notify and verify then document and dispense? Or if different prescribers/pharmacies just verify/annotate and dispense?

If they have insurance and the cash price is cheaper (it almost never is, but I've seen it on stuff like Pre-Op lorazepam) we usually do it like that. If insurance was cheaper and there's no P.A. issues but they insist on cash I don't think we would fill on cash. At least I've never witnessed it.

We check for due of course but yeah we also pay attention to whether the same meds are coming from diff clinics and pharmacies. Or if they get the same stuff from one pharmacy and something else from another pharmacy but only x med at x pharmacy and y med at y pharmacy, etc. if that makes any sense.

 

[PA_dud3]

How do you refuse without endangering yourself? I wouldnt want to fill if its covered with insurance and they insist on cash.

If they get one med from the same pharmacy all the time and another med from the other... do u just call md to notify and verify then document and dispense? Or if different prescribers/pharmacies just verify/annotate and dispense?

I don't really refuse, I'm not really sure what the pharmacist's philosophy in that situation would be. I honestly can't think of a time when ins. covered it but they insisted on cash, most of the time if they are ducking the registry they just don't mention ins (assuming it is a first time pt). Sometimes we check the medicaid database even if they say "no ins." to see if they are being sketchy if the registry doesn't reveal anything. If it shows it then as being too soon we just tell them that it's too soon and if they want it back we give it back, etc. We've caught a couple people like that, that I can remember.

I actually witnessed the latter recently. Pt was getting phentermine at like 4 different locations and always cash, but no one bothered to check the registry but us. In this case we called the prescribing physician. We didn't dispense. If they are getting the same thing from the same pharmacy though we just document and dispense (most of the time, as you probably know there are always exceptions).

 

[CetiAlphaFive]

hey guys,

In my state we’re not required to check pmp as pharmacists although drs are. I still check to make sure pt isnt getting the same med filled twice in the same month. I never really focused on whether they got it from diff prescribers, different pharmacies, and different payment methods bc i was primarily focused on whether they are due or not. After all, what if they go to a clinic and see diff drs or a hospital. We cant control every aspect. I’m curious to hear how other rphs do it.

Also, if a patient wants to pay for a control with cash, I guess its okay if their insurance doesnt cover that med or if they once had insurance and now its expired. If they have insurance and it covers the control and they still want to buy it cash for whatever reason, that seems fishy to me but how can you refuse without endangering yourself? Or if they have no insurance would you refuse cash patients? Not sure how to go about it without pissing them off or having them slash my tires or wait to stab me lol

If they don't have insurance, I check the PMP using the info from their driver's license

if they dont have insurance then you fill with cash, but if they have insurance and it pays for it but they specifically ask you to do it on cash... do you guys do it?

also on pmp do you guys just check for whether theyre due or not or also focus on the other red flags like diff pharmacies/drs/payment methods?

Why wouldn't anyone do both?

How do you refuse without endangering yourself? I wouldnt want to fill if its covered with insurance and they insist on cash.
If they get one med from the same pharmacy all the time and another med from the other... do u just call md to notify and verify then document and dispense? Or if different prescribers/pharmacies just verify/annotate and dispense?

Nobody on SDN can teach you street smarts.

Either they think you look like a victim or they don't

 

[beautifulrobot]

if they dont have insurance then you fill with cash, but if they have insurance and it pays for it but they specifically ask you to do it on cash... do you guys do it?

It depends on the drug and whether there are any other red flags.

One reason why some folks might insist on paying cash is because filling a prescription for a psychiatric drug like a benzodiazepine or stimulant could potentially derail their career aspirations. Paying cash (both for the doctor visit and the Rx) helps reduce the risk of current/future employers finding out about the prescription. Whether that's ethical or not is debatable, but a part of me is sympathetic towards people wanting to have more control over their PHI and deciding when/how to disclose sensitive medical information, and ultimately feel that it's none of my business. As long as there are no safety issues with the Rx or other red flags for diversion, I would be fine with letting folks pay cash for some controls even if I know they have insurance.

 

[johnpharm01]

hey guys,

In my state we’re not required to check pmp as pharmacists although drs are. I still check to make sure pt isnt getting the same med filled twice in the same month. I never really focused on whether they got it from diff prescribers, different pharmacies, and different payment methods bc i was primarily focused on whether they are due or not. After all, what if they go to a clinic and see diff drs or a hospital. We cant control every aspect. I’m curious to hear how other rphs do it.

Also, if a patient wants to pay for a control with cash, I guess its okay if their insurance doesnt cover that med or if they once had insurance and now its expired. If they have insurance and it covers the control and they still want to buy it cash for whatever reason, that seems fishy to me but how can you refuse without endangering yourself? Or if they have no insurance would you refuse cash patients? Not sure how to go about it without pissing them off or having them slash my tires or wait to stab me lol

Well our job as pharmacists is to ensure appropriate drug use and controls, while effective and necessary for medical conditions, can be abused and misused. We need to deter that. I look at the overall picture when filling a control. A customer requesting to pay cash is a red flag. Add a few more red flags and I won't fill your prescription i.e. fills at multiple pharmacies, multiple drs, excessive dose. I'll be honest with the customer and its not always well received, but its well intended. You will want to review your companies policies and procedures along with state rules, reg and law. Don't be indifferent because that will draw in those that apparently abuse it. Welcome to the big leagues.

 

[MARX22]

In my state even if you pay cash it will still show on the registry so even if they lie about not having insurance, there’s really no way to escape the registry thankfully.

Wow, from a few different pharmacies and all cash? Were they getting it within a few days of each other, meaning they weren’t even due that’s why they were pharmacy hopping? Did the prescriber tell you he/she wasn’t aware and for you not to dispense, or did you guys flat out refuse the dr?

I don't really refuse, I'm not really sure what the pharmacist's philosophy in that situation would be. I honestly can't think of a time when ins. covered it but they insisted on cash, most of the time if they are ducking the registry they just don't mention ins (assuming it is a first time pt). Sometimes we check the medicaid database even if they say "no ins." to see if they are being sketchy if the registry doesn't reveal anything. If it shows it then as being too soon we just tell them that it's too soon and if they want it back we give it back, etc. We've caught a couple people like that, that I can remember.

I actually witnessed the latter recently. Pt was getting phentermine at like 4 different locations and always cash, but no one bothered to check the registry but us. In this case we called the prescribing physician. We didn't dispense. If they are getting the same thing from the same pharmacy though we just document and dispense (most of the time, as you probably know there are always exceptions).

 

[MARX22]

That’s a good point you make! However, if your job is going to investigate what you get thru insurance etc, can’t they somehow get a hold of the registry as well to see what you’re getting overall, insurance or not?

It depends on the drug and whether there are any other red flags.

One reason why some folks might insist on paying cash is because filling a prescription for a psychiatric drug like a benzodiazepine or stimulant could potentially derail their career aspirations. Paying cash (both for the doctor visit and the Rx) helps reduce the risk of current/future employers finding out about the prescription. Whether that's ethical or not is debatable, but a part of me is sympathetic towards people wanting to have more control over their PHI and deciding when/how to disclose sensitive medical information, and ultimately feel that it's none of my business. As long as there are no safety issues with the Rx or other red flags for diversion, I would be fine with letting folks pay cash for some controls even if I know they have insurance.

 

[MARX22]

Well our job as pharmacists is to ensure appropriate drug use and controls, while effective and necessary for medical conditions, can be abused and misused. We need to deter that. I look at the overall picture when filling a control. A customer requesting to pay cash is a red flag. Add a few more red flags and I won't fill your prescription i.e. fills at multiple pharmacies, multiple drs, excessive dose. I'll be honest with the customer and its not always well received, but its well intended. You will want to review your companies policies and procedures along with state rules, reg and law. Don't be indifferent because that will draw in those that apparently abuse it. Welcome to the big leagues.

I hear about pharmacists getting their tires slashed or junkies waiting in the lot for them after their shift. That’s the only reason why I’m hesitant regarding straight up refusing due to different pharmacies/mds, esp if theyre getting it on time and it isn’t like theyre getting percocet 30 day supply from next door then coming to get another 30 day supply from me 10 days later. If they’re “due” then it seems majority of rphs just call the dr to confirm that md was aware of pt going to diff dr/pharmacy then they annotate and dispense

 

[MARX22]

So if you do look at other red flags like different payment methods or diff doctors/pharmacies, although the patient isn’t early all the time, what do you do about it? Confirm that md is aware? Or flat out refuse?

Pt could be going to a clinic or hospital and seeing different doctors without really having a say in it or realizing that this can be an issue, esp if its a place where whichever dr is on call sees you. Is it fair to just not dispense merely due to diff doctors? That’s why I’m guessing it’s okay to confirm w the doctor then dispense.

If they don't have insurance, I check the PMP using the info from their driver's license


Why wouldn't anyone do both?


Nobody on SDN can teach you street smarts.

Either they think you look like a victim or they don't

 

[ifillrxs]

https://nabp.pharmacy/wp-content/uploads/2016/07/Red-Flags-Controlled-Substances-03-2015.pdf

This link is a comprehensive list of warning signs of possible diversion exhibited by patients and prescribers. If any of these red flags are present, you should ask questions of the patient and/or prescriber. In the instance of paying cash for a controlled substance, ask why. It is your business to ask why until you are satisfied. Do yourself a favor and ask questions with a compassionate demeanor instead of an accusatory tone and body language. Listen to your patient. At the end of your conversation, tell your patient you will continue evaluating the prescription and get back to him/her. I like to give myself time to think through all the answers and make sense of them. Personally, I can't do it with the patient in my face. According to DEA, if in doubt, DO NOT dispense the controlled substance. That means if you have a red flag and the explanation is not satisfactory to you, don't fill it. You know the feeling you get when you fill a control and you're not entirely sure. Trust that feeling because it comes from your experience and training.

Insurance companies have clinical criteria established for their members. Keep in mind, if you cash out prescriptions on a regular basis to circumvent their guidelines, YOU become the red flag. Now I think we have all filled prescriptions with red flags present. There are good reasons sometimes. Try to avoid any pattern of behavior that puts you at risk.

For guidance on how to refuse to fill a prescription, look to the pharmacy you work for. Ask your colleagues. Consult your state board. Many companies will have specific policies and will advise you on what to say. Again, come from a place of compassion and keep the conversation private. Do not be lured into a shouting scene at the pharmacy window. Most people will not want to hurt you. They just want their prescription filled. Hand the prescription back with the advice that they are welcome to try another pharmacy. If it is clear you won't fill it, they are wasting their time shouting at you.

 

[PA_dud3]

In my state even if you pay cash it will still show on the registry so even if they lie about not having insurance, there’s really no way to escape the registry thankfully.

Wow, from a few different pharmacies and all cash? Were they getting it within a few days of each other, meaning they weren’t even due that’s why they were pharmacy hopping? Did the prescriber tell you he/she wasn’t aware and for you not to dispense, or did you guys flat out refuse the dr?

That's how it's supposed to be in my state. Some people just don't use it, unfortunately.

Yeah, everytime they got it it was always like a month early. Prescriber wasn't aware, and we didn't dispense as we and the prescriber both agreed not to fill.

 

[wagrxm2000]

What do they say when you say why don't you want us to use your insurance? If they don't immediately have a legit reason, I can't think of one anyways, then just say well it's best that we bill it to save you money.

If they still say no, just repeat the exact same line, it's best to bill it to save you money until they give up and leave.

 

[johnpharm01]

I hear about pharmacists getting their tires slashed or junkies waiting in the lot for them after their shift. That’s the only reason why I’m hesitant regarding straight up refusing due to different pharmacies/mds, esp if theyre getting it on time and it isn’t like theyre getting percocet 30 day supply from next door then coming to get another 30 day supply from me 10 days later. If they’re “due” then it seems majority of rphs just call the dr to confirm that md was aware of pt going to diff dr/pharmacy then they annotate and dispense

I worked in a high crime area. The risk can be real, but there are things you can do. Park where the cameras hit, ask for an escort out to your car (from store manager), buy a car like patrick swayze in road house, report all threats to police, take your smock off and leave it at the pharmacy (less identifiable). Drs reps will say ok to almost anything, I call to get information and discuss cases then make MY OWN decision because I have MY OWN responsibility and license.

 

[genesis09]

In Wisconsin, the pmdp lists how the medication was paid for. It will say if there was insurance or not. The one caveat is that those who use discount cards will come up as using commercial insurance.

 

[beautifulrobot]

That’s a good point you make! However, if your job is going to investigate what you get thru insurance etc, can’t they somehow get a hold of the registry as well to see what you’re getting overall, insurance or not?

Yes, but insurance claims are, for now, more damning than PMP registry data. PMP registries have become a lot more functional over the past few years, but they are still pretty siloed compared to insurance claims data, and I am not sure what the longevity of the data in PMP registries are (insurance claims are usually for life at this point). Again, not advocating that people be dishonest or deceitful, but paying cash still allows someone to be a bit more discreet about the medications they are taking, even with PMP registries.

 

[MARX22]

Thanks for the link! We have e rxs in my state so I can’t even hand them the rx back, which stinks. Dont they get pissed off when u tell them u need to think about it? I often get “ur not the doctor why do u guys play doctor” lol.

I dont think the dr’s office can explain why a patient would be going to different pharmacies but they could easily say it was more convenient for them at the time or something. At what point do you just take the patient/dr’s word for it and when do u just say no? I feel like i’ve painted every control user with a broad brush out of fear

https://nabp.pharmacy/wp-content/uploads/2016/07/Red-Flags-Controlled-Substances-03-2015.pdf

This link is a comprehensive list of warning signs of possible diversion exhibited by patients and prescribers. If any of these red flags are present, you should ask questions of the patient and/or prescriber. In the instance of paying cash for a controlled substance, ask why. It is your business to ask why until you are satisfied. Do yourself a favor and ask questions with a compassionate demeanor instead of an accusatory tone and body language. Listen to your patient. At the end of your conversation, tell your patient you will continue evaluating the prescription and get back to him/her. I like to give myself time to think through all the answers and make sense of them. Personally, I can't do it with the patient in my face. According to DEA, if in doubt, DO NOT dispense the controlled substance. That means if you have a red flag and the explanation is not satisfactory to you, don't fill it. You know the feeling you get when you fill a control and you're not entirely sure. Trust that feeling because it comes from your experience and training.

Insurance companies have clinical criteria established for their members. Keep in mind, if you cash out prescriptions on a regular basis to circumvent their guidelines, YOU become the red flag. Now I think we have all filled prescriptions with red flags present. There are good reasons sometimes. Try to avoid any pattern of behavior that puts you at risk.

For guidance on how to refuse to fill a prescription, look to the pharmacy you work for. Ask your colleagues. Consult your state board. Many companies will have specific policies and will advise you on what to say. Again, come from a place of compassion and keep the conversation private. Do not be lured into a shouting scene at the pharmacy window. Most people will not want to hurt you. They just want their prescription filled. Hand the prescription back with the advice that they are welcome to try another pharmacy. If it is clear you won't fill it, they are wasting their time shouting at you.

 

[MARX22]

Bet that doctor wasn’t going to treat that patient anymore, haha

That's how it's supposed to be in my state. Some people just don't use it, unfortunately.

Yeah, everytime they got it it was always like a month early. Prescriber wasn't aware, and we didn't dispense as we and the prescriber both agreed not to fill.

 

[MARX22]

I can totally picture how that would go down.. “can i speak to your manager, clearly you don’t understand english—CASH IT OUT IT ISN’T YOUR BUSINESS WHETHER I SAVE MONEY OR NOT”! Lol

What do they say when you say why don't you want us to use your insurance? If they don't immediately have a legit reason, I can't think of one anyways, then just say well it's best that we bill it to save you money.

If they still say no, just repeat the exact same line, it's best to bill it to save you money until they give up and leave.

 

[MARX22]

Interesting. These people terrify me since they’re usually hooked on these drugs and want it their way or the highway

Would you speak to the doctor when it comes to controls or their reps even then? I dont think the dr or even their rep can explain why a patient would be going to different pharmacies but they could easily say it was more convenient for them at the time or something.

I worked in a high crime area. The risk can be real, but there are things you can do. Park where the cameras hit, ask for an escort out to your car (from store manager), buy a car like patrick swayze in road house, report all threats to police, take your smock off and leave it at the pharmacy (less identifiable). Drs reps will say ok to almost anything, I call to get information and discuss cases then make MY OWN decision because I have MY OWN responsibility and license.

 

[ifillrxs]

Thanks for the link! We have e rxs in my state so I can’t even hand them the rx back, which stinks. Dont they get pissed off when u tell them u need to think about it? I often get “ur not the doctor why do u guys play doctor” lol.

I dont think the dr’s office can explain why a patient would be going to different pharmacies but they could easily say it was more convenient for them at the time or something. At what point do you just take the patient/dr’s word for it and when do u just say no? I feel like i’ve painted every control user with a broad brush out of fear

Erxs definitely complicate things because you can't hand the rx back to the patient. I have only denied one. I would never use the phrase "I have to think about it". Yes that would make most people angry. I know I would be. Stay as professional and as deliberate as possible with your body language to show you are confident. After talking to a patient, I'll say thank you for talking to me and I'm that I'm going to continue the process. If you need to, explain it is a lengthy, time consuming, process to fill some prescriptions. If someone says you're not the doctor, why do you play doctor, probably any response I give will sound condescending and snarky. I wouldn't engage with an answer. I would restate that I need to follow a dispensing policy that is lengthy and time consuming. That is what a pharmacist is required to do. At any time a patient is free to go elsewhere.

I feel there is a paradigm shift regarding the doctor/pharmacist relationship. It used to be we would call the doctor to document an early fill for whatever reason. Now I feel we have more control and they ask us.

Look at how many state's attorney generals are suing pharmacies, drug distributors, and manufacturers. They are putting the blame on us for the opiate epidemic.

 

[CetiAlphaFive]

Erxs definitely complicate things because you can't hand the rx back to the patient. I have only denied one. I would never use the phrase "I have to think about it". Yes that would make most people angry. I know I would be. Stay as professional and as deliberate as possible with your body language to show you are confident. After talking to a patient, I'll say thank you for talking to me and I'm that I'm going to continue the process. If you need to, explain it is a lengthy, time consuming, process to fill some prescriptions. If someone says you're not the doctor, why do you play doctor, probably any response I give will sound condescending and snarky. I wouldn't engage with an answer. I would restate that I need to follow a dispensing policy that is lengthy and time consuming. That is what a pharmacist is required to do. At any time a patient is free to go elsewhere.

I feel there is a paradigm shift regarding the doctor/pharmacist relationship. It used to be we would call the doctor to document an early fill for whatever reason. Now I feel we have more control and they ask us.

Look at how many state's attorney generals are suing pharmacies, drug distributors, and manufacturers. They are putting the blame on us for the opiate epidemic.

This is a good post.

Ive noticed the same shift.
The older doctors seem confused when I refuse

 

[PikminOC]

We are required to chk pmp every time we prescribe a controlled sub