Medicaid patient paying cash for drug requiring PA

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BenJammin

BenJammin

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Isn't that illegal? If they can pay cash for it then why are they receiving benefits?
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A: Can somehow pay for a single prescription once. Maybe s/he received help from a friend or family member.

B: This person makes too much money to quality for Medicaid.

How are you getting from A to B?
 
croquemonsieur said:
A: Can somehow pay for a single prescription once. Maybe s/he received help from a friend or family member.

B: This person makes too much money to quality for Medicaid.

How are you getting from A to B?
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Because I was told by a pharmacist in Indiana that his state does not allow it under the theory that if you can pay cash for it, you don't need the government assistance. Didn't know if that was just unique to Indiana.
 
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BenJammin said:
Because I was told by a pharmacist in Indiana that his state does not allow it under the theory that if you can pay cash for it, you don't need the government assistance. Didn't know if that was just unique to Indiana.
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I'm licensed in Indiana and I've never heard this. I wonder if it's just one of those things that people say/believe to be true? I don't think it's illegal, though.
 
BenJammin said:
Isn't that illegal? If they can pay cash for it then why are they receiving benefits?
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Oh, that's interesting. I know next to nothing about Indiana but I'm guessing that's not true. I was just wondering about and commenting on the bolded bit.
 
Pharmacies sell drugs after the MD has given permission to them to sell it to the patient in the form of a prescription.

Once the prescription has been presented, the pharmacy can legally sell the drug to the patient. How the patient pays for it is another matter. Cash or Insurance, it makes no difference from a legal standpoint. (I know there are exceptions to this generality, but this is how it works most of the time).
 
It's state specific. I tell patients they risk their benefits being revoked if Medicaid investigates. And besides, if it's anything more than 20 dollars, they usually won't pay for it.
 
lol illegal? so if medicaid doesn't cover your meds, you're gonna have to walk it off if you have cancer, aids, or any other illness.
 
boriqua said:
lol illegal? so if medicaid doesn't cover your meds, you're gonna have to walk it off if you have cancer, aids, or any other illness.
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No, you wait for the PA to come through. If you can pay out of pocket for Linezolid then why are you on medicaid?
 
BenJammin said:
No, you wait for the PA to come through. If you can pay out of pocket for Linezolid then why are you on medicaid?
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lol i don't know what kind of candyland you live in but the number of people that are on medicaid that shouldn't be is astounding.
but whether or not someone should or should not be on medicaid is completely irrelevant to what you are asking
you asked if it was illegal for the pharmacy to accept cash payment. the answer is no.
 
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boriqua said:
lol i don't know what kind of candyland you live in but the number of people that are on medicaid that shouldn't be is astounding.
but whether or not someone should or should not be on medicaid is completely irrelevant to what you are asking
you asked if it was illegal for the pharmacy to accept cash payment. the answer is no.
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That's not what I asked. I don't understand why you're bringing up irrelevant facts like medicaid totals so I have no response to your post.

Waffle Houzen said:
Aaaaand it's also illegal for Medicaid patients to possess iphones. If you see them using an iphone, legally you're obligated to snatch it right out of their grubby hands. Old flip-phones are okay though.
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Apples and oranges.
 
-_- this dude doesn't remember his own question. scroll up.

"If they can pay cash for it then why are they receiving benefits?"
 
boriqua said:
-_- this dude doesn't remember his own question. scroll up.

"If they can pay cash for it then why are they receiving benefits?"
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Paying cash for a script not on or covered by insurance is different from paying cash for a script requiring a PA.
 
Under the new ACA rules, states (at least some) that expanded Medicaid got rid of the asset limit and allow individuals to qualify based on reported income alone. Therefore, it probably won't be uncommon that someone will have little or no income but plenty of savings.
 
boriqua said:
lol i don't know what kind of candyland you live in but the number of people that are on medicaid that shouldn't be is astounding.
but whether or not someone should or should not be on medicaid is completely irrelevant to what you are asking
you asked if it was illegal for the pharmacy to accept cash payment. the answer is no.
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And there are a lot of people who aren't getting Medicaid who should. Lots of senior citizens are qualified and have no idea that they are.
 
stoichiometrist said:
Under the new ACA rules, states (at least some) that expanded Medicaid got rid of the asset limit and allow individuals to qualify based on reported income alone. Therefore, it probably won't be uncommon that someone will have little or no income but plenty of savings.
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Maybe not savings, but that they would own property.
 
In Illinois, there is a limit of 4 RX's/30 days (they do make exceptions for certain drugs if the doctor does a PA), Medicaid encourages their recipients to pay cash to get any RX's they need over the 4 (and certainly any that require a PA for any other reason.) I've seen some of the PA's put in for being over 4 RX's/30 days denied because because the drug was cheap enough that the case worker thought they should be able to afford it. I think IL Medicaid does keep track of paying cash for narcotics (because of refill too soon) and that can have repercussions.

At any rate....unless the drug is something ridiculous like Latisse, I don't worry about where they are getting them money to pay for it-its their money, qualifying for Medicaid (at least in IL) doesn't mean that one is destitute with no disposable income. I guess even with Latisse, maybe they have a sugar daddy buying it for them.
 
BenJammin said:
Paying cash for a script not on or covered by insurance is different from paying cash for a script requiring a PA.
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When it comes to legality for the pharmacy, no it is not. the pharmacy wont get in trouble period. it may prompt an investigation from medicaid to see if the person should really be on medicaid(although highly unlikely). I'm not sure if you were asking as a medicaid recipient or a pharmacist dealing with this situation. You sure don't sound like you practice retail pharmacy. wait for the doctor to authorize the PA? what a joke. Been a retail pharmacist for nearly 2 years. I average about 30-40 PA rejections per day and i can count on my fingers how many times a doctor ever actually went through with the process of a PA. I don't really know what the process for the physician PA's are but it's enough of a hassle where they exhaust every other option before they do it. I remember calling a doctor about getting a PA once. he tried changing the medication 3 times to other medications of the same class. all were not covered. then he started asking the prices of each medication and ended up just picking the cheapest one and told us to tell the patient to pay out of pocket. I got a patient that's been waiting on a PA since January. Called the doctor last week to follow up. "we're working on it". dude's been paying cash for his meds. in your world, he'd pretty much have to walk it off right?
 
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boriqua said:
When it comes to legality for the pharmacy, no it is not. the pharmacy wont get in trouble period. it may prompt an investigation from medicaid to see if the person should really be on medicaid(although highly unlikely). I'm not sure if you were asking as a medicaid recipient or a pharmacist dealing with this situation. You sure don't sound like you practice retail pharmacy. wait for the doctor to authorize the PA? what a joke. Been a retail pharmacist for nearly 2 years. I average about 30-40 PA rejections per day and i can count on my fingers how many times a doctor ever actually went through with the process of a PA. I don't really know what the process for the physician PA's are but it's enough of a hassle where they exhaust every other option before they do it. I remember calling a doctor about getting a PA once. he tried changing the medication 3 times to other medications of the same class. all were not covered. then he started asking the prices of each medication and ended up just picking the cheapest one and told us to tell the patient to pay out of pocket. I got a patient that's been waiting on a PA since January. Called the doctor last week to follow up. "we're working on it". dude's been paying cash for his meds. in your world, he'd pretty much have to walk it off right?
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^ is reality.
 
Also when they come up to your drive-thru and are smoking cigs section C subsection 23 of the Medicaid standard operations of procedure for reporting Medicaid fraud states you must first extinguish his/her cig with a squirt bottle while in mouth before reporting.

Oh and make him/her pay cash for their ventolin.
 
There's no way a pharmacist can verify the origin of said funds used. Even if your state has some weird regulation on the books, it's practically unenforceable.
 
I am confused how Medicaid would know if a patient paid cash for a medicine in the first place. Won't they just see a reversed claim for a PA required med? How would they know the patient paid cash for it? I am legitimately curious. Do pharmacies send payment info to Medicaid? Also I know if FL "PA required" is code for "will not pay". I have had a few local doctors and patients tell me that their PA requests are always denied.
 
I am a CPhT who works in WA state. Here there are about 3 different state insurances; Express Scripts, WA Medicaid and CUP (MODA or Apple). If the patient has Express Scripts or MODA, they CANNOT pay cash for the medicine. Regardless if it requires a PA or not, the pharmacy should not be processing the script. In this case the med needs to be changed or a PA started in which the patient simply has to wait (I know its not that simple but that is the only option they get). Some patients at this point will opt to take the hard copy back and take it somewhere that does not accept Express/MODA as an insurance so they won't have a problem. If the patient has Medicaid, there is a form the patient fills out saying they understand it is not covered, etc, etc and are willing to pay for it. That's pretty much it, once that form is signed they can pay cash for whatever they want. I don't believe Medicaid has anyway to track these or really cares enough to try it.
 
I think there is a law somewhere that Medicaid patients can receive up to a 3 day supply of any drug that needs a PA. Anyone know what I'm vaguely remembering?
 
Vesthria said:
I am a CPhT who works in WA state. Here there are about 3 different state insurances; Express Scripts, WA Medicaid and CUP (MODA or Apple). If the patient has Express Scripts or MODA, they CANNOT pay cash for the medicine. Regardless if it requires a PA or not, the pharmacy should not be processing the script. In this case the med needs to be changed or a PA started in which the patient simply has to wait (I know its not that simple but that is the only option they get). Some patients at this point will opt to take the hard copy back and take it somewhere that does not accept Express/MODA as an insurance so they won't have a problem. If the patient has Medicaid, there is a form the patient fills out saying they understand it is not covered, etc, etc and are willing to pay for it. That's pretty much it, once that form is signed they can pay cash for whatever they want. I don't believe Medicaid has anyway to track these or really cares enough to try it.
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I honestly don't believe you. I think that's a myth. Can you cite the law?
 
zelman said:
I think there is a law somewhere that Medicaid patients can receive up to a 3 day supply of any drug that needs a PA. Anyone know what I'm vaguely remembering?
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You are probably thinking of an emergency supply. At the discretion of the pharmacist, he/she can give the patient 3 days worth of a non-controlled/narcotic prescription while we wait for a PA or a new script.
Carboxide said:
I honestly don't believe you. I think that's a myth. Can you cite the law?
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I don't have a set of the rules at my house but that is basically what every technician is taught when working in my state. This issue came about when a pharmacy chain allowed Express Scripts patients to pay cash for scripts; even in the event that the patient was trying to get it too soon (based on the insurance). Because of this, the entire chain lost its contract with Express and could not bill any insurance through that processor. Of coarse that doesn't stop patients from taking the hard copy and bringing it to them to fill anyway to get around the 'too soon' issue with their insurance. If you really want, I can try looking up some of that when I work next but it is something that pharmacies were fearing in case they loose their contract as well. So if they are willing to risk it, they could potentially run it as cash but if they get audited they can loose their contract to bill Express Scripts.
 
Vesthria said:
You are probably thinking of an emergency supply. At the discretion of the pharmacist, he/she can give the patient 3 days worth of a non-controlled/narcotic prescription while we wait for a PA or a new script.


I don't have a set of the rules at my house but that is basically what every technician is taught when working in my state. This issue came about when a pharmacy chain allowed Express Scripts patients to pay cash for scripts; even in the event that the patient was trying to get it too soon (based on the insurance). Because of this, the entire chain lost its contract with Express and could not bill any insurance through that processor. Of coarse that doesn't stop patients from taking the hard copy and bringing it to them to fill anyway to get around the 'too soon' issue with their insurance. If you really want, I can try looking up some of that when I work next but it is something that pharmacies were fearing in case they loose their contract as well. So if they are willing to risk it, they could potentially run it as cash but if they get audited they can loose their contract to bill Express Scripts.
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Filling something too soon is VERY VERY different from letting a patient pay cash for a PA med.
 
coarse? loose?

anyways, breaking the law and breaking a contract is two different things. you're probably misinterpreting your company policy and not the law or contract.
 
Carboxide said:
Filling something too soon is VERY VERY different from letting a patient pay cash for a PA med.
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Yet the patient would want to pay cash regardless which reason above is the problem.

HouTX said:
coarse? loose?

anyways, breaking the law and breaking a contract is two different things. you're probably misinterpreting your company policy and not the law or contract.
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Your right I did probably misinterpret the question with law and policy.

zelman said:
No. See section 2705.1 in this document: http://dhcf.dc.gov/sites/default/fi...ts/MedicaidRegPharmacyServicesNoticeFinal.pdf

I believe every state medicaid program must have some similar law on the books in order to receive federal funding.
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Like I said, if the pharmacist gives an okay then we can. However, think about from a different point of view. On average a PA would take longer than 3 business days to get a response (not including if it was a weekend which would take even longer). So would you recommend the pharmacy give the patient 3 capsules of Lyrica, have the PA not be done when the capsules are out so the patient would want more to keep the therapy going, and then have the PA denied? The pharmacy would then have to eat the difference of loosing the now 5-7 Lyrica that we both know the patient would not pay for on their own.
 
Im sorry, I am getting offtrack. Bottom line, yes they can pay cash unless your state says otherwise.
 
Vesthria said:
Like I said, if the pharmacist gives an okay then we can. However, think about from a different point of view. On average a PA would take longer than 3 business days to get a response (not including if it was a weekend which would take even longer). So would you recommend the pharmacy give the patient 3 capsules of Lyrica, have the PA not be done when the capsules are out so the patient would want more to keep the therapy going, and then have the PA denied? The pharmacy would then have to eat the difference of loosing the now 5-7 Lyrica that we both know the patient would not pay for on their own.
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3 Days worth is their legal right, and should be reimbursed (you will not take a loss). It's not really your (pharmacist's) call (with the exception of packages not to be broken e.g. Pradaxa)
 
there's an override you put in the computer to get a 3 day supply to go through. also supposedly works for inhalers, you just have to change the days supply to 3
 
Vesthria said:
Yet the patient would want to pay cash regardless which reason above is the problem.



Your right I did probably misinterpret the question with law and policy.



Like I said, if the pharmacist gives an okay then we can. However, think about from a different point of view. On average a PA would take longer than 3 business days to get a response (not including if it was a weekend which would take even longer). So would you recommend the pharmacy give the patient 3 capsules of Lyrica, have the PA not be done when the capsules are out so the patient would want more to keep the therapy going, and then have the PA denied? The pharmacy would then have to eat the difference of loosing the now 5-7 Lyrica that we both know the patient would not pay for on their own.
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I routinely get PAs to go through within 48 hours. As far as the bolded statement, them paying cash is NOT the problem. The problem is trying to fill controls early. Paying cash for a med requiring PA is not a problem. In my state, ondansetron is often PA required. Why would it be a problem? The patient wants to buy 30 tablets of Zofran...go for it, I am all for them not having chemotherapy induced nausea and vomiting.

If a patient is paying cash for a med, it does not mean they do not deserve Medicaid. It means that for whatever reason, they prioritize that medication over other things - sometimes including food. Some people abuse the system, yes, but a lot of patients are truly in need and simply decide that their medications are more important than other expenses.
 
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