Initiating RX claims to find out prices, without having the hard copy

[pharm B]

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Doctor M, you make a good point about doing the little things for the patients, but while I wish it was a universal idea, it might not be.

As a tech working for a major retail chain, I didn't really have any company loyalty. Techs, and employees in general, were a dime a dozen. When customers called around looking for the cheapest meds (not always the scenario in which they ask for a price), they tend to want quick answers and just want to know who has the cheapest price. You could care about them and want to take care of them, and they wouldn't give a crap if you charged $5 more for a med than Competitor Drug Store.

You have every incentive to take care of and satisfy your patient if you're in an independent scenario. What I saw as a tech: As a drone at a bottom-dollar chain that cuts prices to the bone to kill their competition, you just have to make sure you give the right med to the right person when you get paid. There's no emotional component to it, some days. The patient screams if something isn't covered, or if their copay is higher than anticipated, but otherwise have no interest in what you have to offer.

 

[kvl1027]

As someone who has worked for a place that was audited more times I can count, I can tell you that it is legally considered fraud to bill for a prescription which you do not legally possess. In some states, you can have your license revoked just for that.

And depending on how your contract is setup, the majority of the time you are billed for that submission and a reversal will not get rid of that charge. If, for whatever reason, you are audited by the PBM or a state/federal agency and they happen to audit that particular transaction... well you're screwed.

The odds that they will leave for another pharmacy because you won't check a copay price is a bit ridiculous. If they're going to leave for that reason, they wouldn't be worth having as a patient anyways because they'll find some other minute reason to bolt.

Remember, just because they want to give your pharmacy business, does not always mean that it is good business.

Your thought process is a little incorrect. As an Independent pharmacy, we need all the legitimate business we can drum up. We all have customers we like and don't like, probably a good 50/50 mix. To say that a customer who is a bit needed is not worth your time will sink your business faster that a technician who is stealing Oxycontin 80's from you once a month. Almost every customer is worth having from a business stand point, unless they are the junkies who are always to to bring in scripts from Ft. Lauderdale.

An insurance company can't burn you, even on an audit, if you file a claim and reverse the claim. Once the claim is reversed, they haven't paid you anything, and there is no reason to audit you on that claim. Insurance companies audit you on claims they are interested in getting their money back on. Not claims, in which they haven't paid you anything. If they did say, "Why did you run a claim for Zyvox on 6/8/11, and then reverse the claim?" answer: We did not have it in stock, so the patient took it somewhere else, simple. But, they are not going to ask that question anyways.
They ask questions like "Why did you bill 2 boxes of migranol nasal spray for a 30 days supply?"

 

[phathead]

Your thought process is a little incorrect. As an Independent pharmacy, we need all the legitimate business we can drum up. We all have customers we like and don't like, probably a good 50/50 mix. To say that a customer who is a bit needed is not worth your time will sink your business faster that a technician who is stealing Oxycontin 80's from you once a month. Almost every customer is worth having from a business stand point, unless they are the junkies who are always to to bring in scripts from Ft. Lauderdale.

An insurance company can't burn you, even on an audit, if you file a claim and reverse the claim. Once the claim is reversed, they haven't paid you anything, and there is no reason to audit you on that claim. Insurance companies audit you on claims they are interested in getting their money back on. Not claims, in which they haven't paid you anything. If they did say, "Why did you run a claim for Zyvox on 6/8/11, and then reverse the claim?" answer: We did not have it in stock, so the patient took it somewhere else, simple. But, they are not going to ask that question anyways.
They ask questions like "Why did you bill 2 boxes of migranol nasal spray for a 30 days supply?"

I've worked for independents for almost ten years, so I'm well aware of the inherent need for customers, and I still stick by my statement. If a customer is going to leave your pharmacy for not checking a price, they're going to leave for some other minor reason.

Then you'll have to transfer our their Rxs. And you'll lose money on what you had filled. And then you may be stuck with meds on your shelf that they used and no one else used.

Again, if they're going to leave that easily, they're not worth having.

 

[Doctor M]

Doctor M, you make a good point about doing the little things for the patients, but while I wish it was a universal idea, it might not be.

As a tech working for a major retail chain, I didn't really have any company loyalty. Techs, and employees in general, were a dime a dozen. When customers called around looking for the cheapest meds (not always the scenario in which they ask for a price), they tend to want quick answers and just want to know who has the cheapest price. You could care about them and want to take care of them, and they wouldn't give a crap if you charged $5 more for a med than Competitor Drug Store.

You have every incentive to take care of and satisfy your patient if you're in an independent scenario. What I saw as a tech: As a drone at a bottom-dollar chain that cuts prices to the bone to kill their competition, you just have to make sure you give the right med to the right person when you get paid. There's no emotional component to it, some days. The patient screams if something isn't covered, or if their copay is higher than anticipated, but otherwise have no interest in what you have to offer.

LoL, where do you think a lot of our patients came from? They came from doing the little things for patients at a really busy chain store (avg 550-600 rx daily). I offered what ever i could to anyone that walked in the door. If they came back, Awesome, if not, no harm done. I was a drone as well, that never changed working for a chain store. So what? I say do what you can for whoever walks in that door. That has worked for me.

 

[Doctor M]

I've worked for independents for almost ten years, so I'm well aware of the inherent need for customers, and I still stick by my statement. If a customer is going to leave your pharmacy for not checking a price, they're going to leave for some other minor reason.

Then you'll have to transfer our their Rxs. And you'll lose money on what you had filled. And then you may be stuck with meds on your shelf that they used and no one else used.

Again, if they're going to leave that easily, they're not worth having.

If a customer is going to leave your store, its NOT going to be because you didnt check a price. Something else usually prevailed, something that really pissed them off. And again, I will do whatever i can for the patient within the limits of the law. Every patient is worth keeping. Every patient will contribute to your bottom line. Unless the patient is doing something illegal,shady,or aggressively abusive, then they are all worth keeping.

 

[phathead]

LoL, where do you think a lot of our patients came from? They came from doing the little things for patients at a really busy chain store (avg 550-600 rx daily). I offered what ever i could to anyone that walked in the door. If they came back, Awesome, if not, no harm done. I was a drone as well, that never changed working for a chain store. So what? I say do what you can for whoever walks in that door. That has worked for me.

I will bend over backwards for patients. I once drove to a clinic to pick up a new Oxy script for a little old lady because the doc accidentally checked DAW and it was a Friday afternoon. If you want to succeed in pharmacy, especially non-chain, you need to offer unbelievable service.

That part I get. But I draw the line when it comes to thinks that may skirt laws. Everything I have been told by PBMs stated that this is a huge no-no, so I won't risk a PBM contract or license simply to check something that they could do themselves.

 

[kvl1027]

I've worked for independents for almost ten years, so I'm well aware of the inherent need for customers, and I still stick by my statement. If a customer is going to leave your pharmacy for not checking a price, they're going to leave for some other minor reason.

Then you'll have to transfer our their Rxs. And you'll lose money on what you had filled. And then you may be stuck with meds on your shelf that they used and no one else used.

Again, if they're going to leave that easily, they're not worth having.

I take it your plan is to work for a retail chain when you finish school? You may believe that your methodology is the most correct, but I think the owner of the store you work for may have some different thoughts. Why don't you give me his/her email so we can discuss this issue together over email cc:? I would be interested in getting their opinion.

If you do plan on opening your own store some day I can help with a slogan:

PhatHead Pharmacy
"Where our level of caring is based on your level of commitment"

Good Luck to you.

 

[Doctor M]

I will bend over backwards for patients. I once drove to a clinic to pick up a new Oxy script for a little old lady because the doc accidentally checked DAW and it was a Friday afternoon. If you want to succeed in pharmacy, especially non-chain, you need to offer unbelievable service.

That part I get. But I draw the line when it comes to thinks that may skirt laws. Everything I have been told by PBMs stated that this is a huge no-no, so I won't risk a PBM contract or license simply to check something that they could do themselves.

with over 6 billion prescriptions filled yearly, i highly doubt you running a "dummy" claim to check a price for a patient is going to trigger any sort of audit in which you may risk losing your contract or license. I find your line of thinking difficult to understand. Buy hey, what the heck do I know, im just a small store on the corner!

 

[kvl1027]

with over 6 billion prescriptions filled yearly, i highly doubt you running a "dummy" claim to check a price for a patient is going to trigger any sort of audit in which you may risk losing your contract or license. I find your line of thinking difficult to understand. Buy hey, what the heck do I know, im just a small store on the corner!

Exactly! As I said before and as you know from experience, They don't spend money on audits to investigate claims that didn't cost them anything. I don't understand his thought process either.

BTW, How has business been in the Clearwater Area? Are you an API/AAP member?

 

[Doctor M]

Exactly! As I said before and as you know from experience, They don't spend money on audits to investigate claims that didn't cost them anything. I don't understand his thought process either.

BTW, How has business been in the Clearwater Area? Are you an API/AAP member?

Business is great! Taking a week off. Today is day 1! Was in South beach 2 weekends ago for a little R and R! Going to NY to visit the Rents! Business is good, Money is good, and the time off is good! We are an API/AAP member. Hows business out there?

 

[kvl1027]

Business is great! Taking a week off. Today is day 1! Was in South beach 2 weekends ago for a little R and R! Going to NY to visit the Rents! Business is good, Money is good, and the time off is good! We are an API/AAP member. Hows business out there?

Did you get out to Nashville for the Conference in April? I was there with my wife and we had a really good time.

Business has been good. We are winding down now, all the snow birds are heading back up, so I will be looking forward to taking a vacation soon.

 

[Doctor M]

Did you get out to Nashville for the Conference in April? I was there with my wife and we had a really good time.

Business has been good. We are winding down now, all the snow birds are heading back up, so I will be looking forward to taking a vacation soon.

No, didnt make it to nashville. Are you going to Las Vegas for RBC cardinal? Vaca is always good!!

 

[kvl1027]

No, didnt make it to nashville. Are you going to Las Vegas for RBC cardinal? Vaca is always good!!

Unfortunately I will not be going to Cardinal. The boss has decided it would be a good opportunity for him to take his whole family on a vaca. The only issue I am have difficulty with is that there will not really be anyone there taking care of the things that need to be done business wise. Just a big fun-fest for everyone.

I believe the owner is essentially done growing the business and just has things on auto-pilot. I am the only one who seems to care sometimes, I don't understand it, but I am hanging in there for the opportunity to perhaps buy this store or at the very least learn enough to run my own store, which frankly I'm almost there.

Maybe next year I will catch you at API, maybe next year I will have my own store, who knows.

 

[Jabberwocky12]

Hey Doc does your pharmacy have a webpage?

Mind if I take a look at it? Or can you PM me if you don't want it broadcasted? I'm quite curious to see how your pharmacy is formatted. I'm of course thing years and years down the line but I'd like to get some ideas of opening a pharmacy one day as well and a model to compare to others with known success would be fantastic.

 

[Doctor M]

Hey Doc does your pharmacy have a webpage?

Mind if I take a look at it? Or can you PM me if you don't want it broadcasted? I'm quite curious to see how your pharmacy is formatted. I'm of course thing years and years down the line but I'd like to get some ideas of opening a pharmacy one day as well and a model to compare to others with known success would be fantastic.

www.lifecare-rx.com

 

[meister]

I can only imagine the nightmare that could erupt if a "dummy" prescription somehow made its way through.

Uhh, an amusing moment when you scan a blank rx with a smiley face on it? Are you really that much of a wuss in real life? As long as you reverse the claim literally no one in the universe cares.

 

[Doctor M]

Uhh, an amusing moment when you scan a blank rx with a smiley face on it? Are you really that much of a wuss in real life? As long as you reverse the claim literally no one in the universe cares.

👍

 

[Carboxide]

Your thought process is a little incorrect. As an Independent pharmacy, we need all the legitimate business we can drum up. We all have customers we like and don't like, probably a good 50/50 mix. To say that a customer who is a bit needed is not worth your time will sink your business faster that a technician who is stealing Oxycontin 80's from you once a month. Almost every customer is worth having from a business stand point, unless they are the junkies who are always to to bring in scripts from Ft. Lauderdale.

An insurance company can't burn you, even on an audit, if you file a claim and reverse the claim. Once the claim is reversed, they haven't paid you anything, and there is no reason to audit you on that claim. Insurance companies audit you on claims they are interested in getting their money back on. Not claims, in which they haven't paid you anything. If they did say, "Why did you run a claim for Zyvox on 6/8/11, and then reverse the claim?" answer: We did not have it in stock, so the patient took it somewhere else, simple. But, they are not going to ask that question anyways.
They ask questions like "Why did you bill 2 boxes of migranol nasal spray for a 30 days supply?"

My pharmacy does NOT give prices without an Rx in front of us. I see your point, but what concerns me is that we should not be put in the position of lying if they do question us about that reversal. If you have any qualms about saying, "I was just doing a price check and did not have the Zyvox Rx in front of me" during an audit, then you should not do it.

 

[Doctor M]

My pharmacy does NOT give prices without an Rx in front of us. I see your point, but what concerns me is that we should not be put in the position of lying if they do question us about that reversal. If you have any qualms about saying, "I was just doing a price check and did not have the Zyvox Rx in front of me" during an audit, then you should not do it.

Wow, Meister is right, although i dont think the word wuss is sufficient. Some of you need to grow some marbles. Dont get defensive, its just my opinion.

 

[pharm B]

Uhh, an amusing moment when you scan a blank rx with a smiley face on it? Are you really that much of a wuss in real life? As long as you reverse the claim literally no one in the universe cares.

The workflow at WalMart requires the pharmacist to visually verify the prescription, so this whole thing is a headache waiting to happen. Scanning, typing, interrupting the regular workflow of the pharmacist, etc.

I'm not a wuss, I'm someone who tries to prevent problems. In our store, the same people aren't at work every day. If a tech comes in a day after the experiment and knows nothing about why this person has a prescription already in the system for Drug X, it can become a headache (you don't see the original when doing refills, etc).

In other systems it might work. I was providing a specific example where it's just a headache.

 

[Ackj]

I see your point, but what concerns me is that we should not be put in the position of lying if they do question us about that reversal.

As if you would be audited for this.
As if they would question the reversal.
As if you would remember this specific prescription out of hundreds that get reversed.

 

[Rxnupe]

with over 6 billion prescriptions filled yearly, i highly doubt you running a "dummy" claim to check a price for a patient is going to trigger any sort of audit in which you may risk losing your contract or license. I find your line of thinking difficult to understand. Buy hey, what the heck do I know, im just a small store on the corner!

Doctor M I agree with you and I found that as a huge stretch- why would an auditor ask for something that they never paid on? What if the customer came to your store ask for the "price" and didn't like the price so you had to delete and hand back the prescription? That scenario happens all the time.

 

[kvl1027]

As if you would be audited for this.
As if they would question the reversal.
As if you would remember this specific prescription out of hundreds that get reversed.

Exactly!

@Carboxide: My point in saying that you could always say the patient went somewhere else, was not to say that I lie to the insurance companies, but more to say that the insurance companies would not be asking you these sorts of questions, because even if you ran a claim on a script that essentially does not exist they would have no way of proving otherwise and it would not be worth their time.

@pharm B: If the tech ran a claim to get a price and then immediately reversed the claim, would it stay in your work-flow even after the reversal? If it would, then I could see how that would be a pain. In our system once the claim is reversed and voided out it is gone from work-flow.

 

[Carboxide]

Exactly!

@Carboxide: My point in saying that you could always say the patient went somewhere else, was not to say that I lie to the insurance companies, but more to say that the insurance companies would not be asking you these sorts of questions, because even if you ran a claim on a script that essentially does not exist they would have no way of proving otherwise and it would not be worth their time.

@pharm B: If the tech ran a claim to get a price and then immediately reversed the claim, would it stay in your work-flow even after the reversal? If it would, then I could see how that would be a pain. In our system once the claim is reversed and voided out it is gone from work-flow.

I agree with that...we don't do it because my pharmacist says not to. It's his decision. Also, we are usually very busy. But I will point out that I was responding to a claim that it's okay to lie to an auditor...and even if the premise is stupid, I don't agree with that. Don't do stuff you aren't comfortable admitting to.

 

[kvl1027]

I agree with that...we don't do it because my pharmacist says not to. It's his decision. Also, we are usually very busy. But I will point out that I was responding to a claim that it's okay to lie to an auditor...and even if the premise is stupid, I don't agree with that. Don't do stuff you aren't comfortable admitting to.

Well, if only Insurance companies operated with the same discretion. I get your point and I appreciate your integrity. With that being said, at this point I probably would just tell the auditor that I ran the claim to check the patient's co-pay amount.

 

[owlegrad]

I like the smiley face prescription idea. I thought about doing something similar one day as it was time to leave - my boss just started letting me take the messages and I thought about sending like the last one through as something like "THANKS BOSS THIS WAS GREAT" or something similar. Decided against it though, might not go over as well as I would like. I forgot to put the date on some of them, so I thought about sending one through that was just the date written over and over again with something like "for all the times I forget it" at the bottom. I might still do that one day.

 

[Thoughtfulsinner]

Grow a pair.

 

[fattunesy]

Let's do some math for fun (we're all nerds here, right?)

Walgreens will be our example company.

As of April 30th there 7709 pharmacies in the chain. We will use $0.02 for the cost of transmitting a claim and ignore the reversal (though I know for a fact from contracts I have reviewed that it can be as high as 0.06 with a 0.02 reversal charge). Let's say for the sake of argument that each store does this 10 times per day. 7709 * 0.02* 10 = $1541.80 per day. Not a lot, but for the year it comes to $562,757. This is all conjecture but it would not suprise me if we found out someone at the corporate office had doen these calculations with much more precise data.

So what does it mean? First of all, it is technically insurance fraud to bill a prescription that does not exist, but it is almost impossible to prove in the cases we are discussing so it is a moot point. PBMs are not going after that. Secondly, the cost is not a ton of money, but it is a litlle mroe than pennies in the aggregate. Thirdly, whether or not it is worth it is very situational. If you are running an independant then ABSOLUTELY a good idea; customer service is everything. For a large chain the time spent doing it, plus the cost of doing it, might not be worth it for the $1.75 above cost plus $1.25 dispensing fee that the Rx will bring in.\

Do I do it? For my regulars, yes. However I look at it as a special service, the customer can easily call the back of the card. What bothers me is not doing it, or being asked to do it, it is when it is DEMANDED that I do it...somehting about that just rubs me the wrong way. That attitude is my major problem with retail; the pharmacy blogs and this forum make it pretty clear I am not alone in that opinion.

 

[Old Timer]

Let's do some math for fun (we're all nerds here, right?)

Walgreens will be our example company.

As of April 30th there 7709 pharmacies in the chain. We will use $0.02 for the cost of transmitting a claim and ignore the reversal (though I know for a fact from contracts I have reviewed that it can be as high as 0.06 with a 0.02 reversal charge). Let's say for the sake of argument that each store does this 10 times per day. 7709 * 0.02* 10 = $1541.80 per day. Not a lot, but for the year it comes to $562,757. This is all conjecture but it would not suprise me if we found out someone at the corporate office had doen these calculations with much more precise data.

First, this does not happen 10 times per day in every single store. Now let's assume the person who calls on the phone is my mother who has moved into your area and is looking for a pharmacy. She takes a fair amount of meds, but my stepfather is diabetic with CHF, CAD, CRF, BPH and just about any other acronym you can think of. Despite the fact my mother is pain in the ass customer, she and my stepfather generate about $25,000.00 per year in business. You don't think Walgreens wants this kind of customer. If not, you need to get your next random drug test because you have to be on some kind of recreational pharmaceuticals.

So what does it mean? First of all, it is technically insurance fraud to bill a prescription that does not exist, but it is almost impossible to prove in the cases we are discussing so it is a moot point. PBMs are not going after that. Secondly, the cost is not a ton of money, but it is a litlle mroe than pennies in the aggregate. Thirdly, whether or not it is worth it is very situational. If you are running an independant then ABSOLUTELY a good idea; customer service is everything. For a large chain the time spent doing it, plus the cost of doing it, might not be worth it for the $1.75 above cost plus $1.25 dispensing fee that the Rx will bring in.\

To get a good customer, it is clearly worth it whether you are a chain or an independent.

What you people fail to understand is this is built into the NCPDP file structure. It is called the Medication Formulary and Benefits Information Transaction Package. If you don't know what the NCPDP is or what they do or what my sentence means, you should STFU and get out of this conversation as you do not have the requisite knowledge to participate.

 

[owlegrad]

What you people fail to understand is this is built into the NCPDP file structure. It is called the Medication Formulary and Benefits Information Transaction Package. If you don't know what the NCPDP is or what they do or what my sentence means, you should STFU and get out of this conversation as you do not have the requisite knowledge to participate.

I know how to check specific meds for specific patients (formulary check, duh), but according to your link (thanks for that!) you can also "obtain the medication formulary and benefit information." Do know how to do this by any chance? Like if a patient's med rejects, can you access the formulary to find out what would be covered?

 

[Old Timer]

I know how to check specific meds for specific patients (formulary check, duh), but according to your link (thanks for that!) you can also "obtain the medication formulary and benefit information." Do know how to do this by any chance? Like if a patient's med rejects, can you access the formulary to find out what would be covered?

I think what they mean by formulary check is what you get: Are they covered and what the copay is. There may be more capabilities. All I'm saying is this is built into data processing system and EVERYBODY follows the NCPDP that includes pharmacies and PBMS

 

[Dr Wario]

Wow...this subject actually got to two pages?

 

[Old Timer]

Wow...this subject actually got to two pages?

Almost Three.....

 

[pharaday]

As I mentioned above I think you are doing the customer a disservice. People need to be responsible for themselves.

I don't feel that calling the pharmacy for a price is being so irresponsible. For those that don't work in retail, I could understand why people would think it was a reasonable place to ask for a price since they know that we obtain the prices to bill them for. There are plenty of things people do (coming in with no insurance card and expecting us to know what plan they have etc.) that I do think are irresponsible, however I disagree that this issue is one of them. I don't think wanting a price is so wrong and that these people need to be taught a lesson. Besides, when insurance links are down and we call the insurance company for a price, we almost NEVER get the right answer. Lastly, I find it hard to believe that most people who stubbornly refuse to do this for patients are so concerned about the few pennies it will cost Walgreens, CVS etc. I think if they are honest with themselves, they will admit that they just don't want to make the effort to do it.

Take a company like CVS with over 6000 stores. If each store does several price check claims a day times 6000 plus stores it can add up.

But when you provide customer service to patients, you gain loyalty. Those few pennies you spend looking up a price will be far outweighed by the gain in business you get when they are satisfied with the service you provide. If they get mad and go elsewhere, you aren't going to make any money from any prescriptions they ever need filled. You have to look at the potential costs AND potential gains.

 

[owlegrad]

I found this while doing some law homework:

FL 465.016 (k)

Failing to make prescription fee or price information readily available by failing to provide such information upon request and upon the presentation of a prescription for pricing or dispensing. Nothing in this section shall be construed to prohibit the quotation of price information on a prescription drug to a potential consumer by telephone.

It made me think of this thread.

 

[sakigt]

Wow...this subject actually got to two pages?

Seriously.

If I were a manager Id hand out gift cards to angry customers too. How are they supposed to know if you didnt do something for a customer because it was illegal vs they should take responsibility and call their 1-800 number when we could have easily handled it.

/flamesuit