Medicare B Rx Reimbursements

[MilknCheerios]

I was wondering if anyone could provide more information on how much Medicare B reimburses pharmacies for filling prescriptions of diabetic testing supplies, nebulizer solutions, and insulin for pumps. I have worked for a chain pharmacy for years filling these Rxs and just happened upon this article from 2013:

Pharmacies unwilling to take loss on insulin for Medicare patients

“It’s a huge issue. All these pharmacies have quit doing it. I understand. They have to make a profit to survive,” patient Lee Carr said.

journalstar.com

If you don't care to read it, at least snipe the title off the link there about a number of pharmacies unwilling to fill Rxs that are a loss of money because Part B doesn't even cover the full cost of the drug. I know that a lot can happen between then and now, but it's got me thinking since reimbursement rates are already razor thin. Reimbursement rates have always lingered in my mind, but my company's policy is to fill the Rx as long as we meet all the necessary criteria. For example, we fax doctors a form to fill out for testing strips and as long as it's done correctly and accepted by our billing department, the Rx is filled for a very low copay (oftentimes $0 if the patient has a supplemental plan). Needless to say, these Rxs are expensive and time-consuming, so is the effort really worth it?

If pharmacies really are losing $ on these Rxs, why doesn't corporate just make a policy to just outright deny them? Note: filling the patient's other drugs is not a good answer to this last question, because quite a few patients use our pharmacy just to fill Part B scripts only.

Insight is appreciated-- especially if you have knowledge of what goes on behind the scenes (i.e. actual cost to the pharmacy to order these products and the actual reimbursement rates themselves). Thanks!

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[Drugsarefun2350]

i think the whole idea is to get those patients that only fill part B drugs to fill their part D drugs at your store as well

 

[Wickett]

Like the prior poster said, it is solely to get people in the door in an attempt to get their other business.

 

[wagrxm2000]

This seems odd. We've never been told not to fill an insulin script.

Anyways yes Walgreens pushes hard to get all diabetes meds. There is no reason to take a loss on test strips but let the customer get the rest of their meds say through mail order.

 

[CynicalIntern]

This seems odd. We've never been told not to fill an insulin script.

Anyways yes Walgreens pushes hard to get all diabetes meds. There is no reason to take a loss on test strips but let the customer get the rest of their meds say through mail order.

Telling a patient that you can't fill their prescription because of the reimbursement is a major violation of every insurance contract that has ever been signed. While there are tightly run independents that can ensure that their staff knows how to phrase that appropriately to not have to get back to the insurance company, there's a zero percent chance that a corporate memo saying "we don't get paid enough on insulin, turn those scripts down" wouldn't be released to FOX NEWS by a jaded whistleblower.

 

[wagrxm2000]

Telling a patient that you can't fill their prescription because of the reimbursement is a major violation of every insurance contract that has ever been signed. While there are tightly run independents that can ensure that their staff knows how to phrase that appropriately to not have to get back to the insurance company, there's a zero percent chance that a corporate memo saying "we don't get paid enough on insulin, turn those scripts down" wouldn't be released to FOX NEWS by a jaded whistleblower.

To me it's probably Medicare that's rejecting it.

 

[CynicalIntern]

To me it's probably Medicare that's rejecting it.

It's actually a valid point (and probably a shrewd business move) that WAG explicitly changed their switch rejection (your 9998 codes) to make it more difficult to actually bill Medicare Part B to inadvertently steer pharmacy staff to bill Part D because "part B wouldn't go through" - you could probably easily offset whatever cost you have in audit chargebacks with the difference in reimbursement between Medicare Part B and Part D. Plus then you wouldn't have to deal with the bad PR of "refusing insulin for the elderly" - I hear regular bitching about the CVS policy to restrict testing supplies to max TID for medicare a year after the fact.

 

[MilknCheerios]

@wagrxm2000 as your name implies, does your manager title allow you to see the spread on Medicare B scripts? What, if anything, can you see about how well it pays?

I hear regular bitching about the CVS policy to restrict testing supplies to max TID for medicare a year after the fact.

When this happened, we got a lot more med B scripts and very few of their other meds. It's annoying to have to put in so much time into these scripts knowing another retailer is filling the easy ones.

 

[abrahamdrinkin]

It's actually a valid point (and probably a shrewd business move) that WAG explicitly changed their switch rejection (your 9998 codes) to make it more difficult to actually bill Medicare Part B to inadvertently steer pharmacy staff to bill Part D because "part B wouldn't go through" - you could probably easily offset whatever cost you have in audit chargebacks with the difference in reimbursement between Medicare Part B and Part D. Plus then you wouldn't have to deal with the bad PR of "refusing insulin for the elderly" - I hear regular bitching about the CVS policy to restrict testing supplies to max TID for medicare a year after the fact.

You don’t get to choose what benefit you bill? It’s always Part B with Medicare.

 

[Sine Cura]

You don’t get to choose what benefit you bill? It’s always Part B with Medicare.

Insulin via pump

 

[abrahamdrinkin]

Insulin via pump

Well that too is supposed to always be part B. It’s not a choice; even if the claims system lets you bill it wrong.

 

[wagrxm2000]

@wagrxm2000 as your name implies, does your manager title allow you to see the spread on Medicare B scripts? What, if anything, can you see about how well it pays?



When this happened, we got a lot more med B scripts and very few of their other meds. It's annoying to have to put in so much time into these scripts knowing another retailer is filling the easy ones.

The only thing I can see is in the history tab which anyone can see.

Is that price accurate? I would like to think so but who knows.

So if you look at a Medicare claim for test strips, it's extremely low for what we pay for them. It's also how you see that discount cards don't pay us anything.

 

[Sine Cura]

Well that too is supposed to always be part B. It’s not a choice; even if the claims system lets you bill it wrong.

The point is the claims processor won't force you to do it. It's a chain-only "reject"

 

[CynicalIntern]

You don’t get to choose what benefit you bill? It’s always Part B with Medicare.

You're missing what I'm saying. If the pharmacy employee bills medicare part B, unless things have changed since I've been there, there will probably be a rejection screen saying something along the lines of "ensure medical necessity, include ICD 10 code, a bunch of other words that the employee isn't going to read because they got a rejection and don't care to find out why the rejection is there" - in contrast, if they bill it to part D, they get the lovely green light and a paid claim, making them think that it's "correct." Is it misbilling? Absolutely. Is it fraud? No, because fraud requires an *intent* to defraud, and the only intent there is Walgreens's intent to staff their pharmacy with people who really should be stocking the candy aisle - as evidence by the 600 PPLs I had to take that begged people to stop billing a 90 day supply as a 30 day supply by changing the days supply without the quantity dispensed,

 

[Wickett]

You're missing what I'm saying. If the pharmacy employee bills medicare part B, unless things have changed since I've been there, there will probably be a rejection screen saying something along the lines of "ensure medical necessity, include ICD 10 code, a bunch of other words that the employee isn't going to read because they got a rejection and don't care to find out why the rejection is there" - in contrast, if they bill it to part D, they get the lovely green light and a paid claim, making them think that it's "correct." Is it misbilling? Absolutely. Is it fraud? No, because fraud requires an *intent* to defraud, and the only intent there is Walgreens's intent to staff their pharmacy with people who really should be stocking the candy aisle - as evidence by the 600 PPLs I had to take that begged people to stop billing a 90 day supply as a 30 day supply by changing the days supply without the quantity dispensed,

If Part D wont cover it, the system in my company rejects and says to bill part B instead. Walgreens' system will just pass it through D even if it didnt actually go through? How does that work?

 

[CynicalIntern]

If Part D wont cover it, the system in my company rejects and says to bill part B instead. Walgreens' system will just pass it through D even if it didnt actually go through? How does that work?

*If* part D won't cover it. This traditionally only happens for things that Part D doesn't cover 99% of the time - like anti-rejection meds, test strips, or immunizations. But insulin is covered by Part D probably 90% of the time, because for patients who self inject rather than infuse, that's where it gets billed. Medicare is not efficient enough / inclined enough to set up blocks on patients upon learning that they have an insulin pump to ensure that pharmacies bill to the correct medicare type - rather, they'll send their auditing agents after them later. Serious question, have you ever had insulin reject at your pharmacy telling you to run it to part B?

 

[MilknCheerios]

Serious question, have you ever had insulin reject at your pharmacy telling you to run it to part B?

Yes. If you bill a patient's prescription for insulin for insulin pump through a Part D plan, the D plan rejection (sometimes) tells you to bill it through part B (medicare).

On topic: If you're a Walgreens employee, I surmise the only way to find out if your reimbursement is fair is to call Danville / Medicare and find out what you're being reimbursed. But, who has time for that?

 

[CynicalIntern]

Yes. If you bill a patient's prescription for insulin for insulin pump through a Part D plan, the D plan rejection (sometimes) tells you to bill it through part B (medicare).

On topic: If you're a Walgreens employee, I surmise the only way to find out if your reimbursement is fair is to call Danville / Medicare and find out what you're being reimbursed. But, who has time for that?

Interesting. I've never seen it. I wish more would do it - it would save a lot of people an audit disaster. But then again - that's probably why they don't.

 

[Aznfarmerboi]

I was wondering if anyone could provide more information on how much Medicare B reimburses pharmacies for filling prescriptions of diabetic testing supplies, nebulizer solutions, and insulin for pumps. I have worked for a chain pharmacy for years filling these Rxs and just happened upon this article from 2013:

Pharmacies unwilling to take loss on insulin for Medicare patients

“It’s a huge issue. All these pharmacies have quit doing it. I understand. They have to make a profit to survive,” patient Lee Carr said.

journalstar.com

If you don't care to read it, at least snipe the title off the link there about a number of pharmacies unwilling to fill Rxs that are a loss of money because Part B doesn't even cover the full cost of the drug. I know that a lot can happen between then and now, but it's got me thinking since reimbursement rates are already razor thin. Reimbursement rates have always lingered in my mind, but my company's policy is to fill the Rx as long as we meet all the necessary criteria. For example, we fax doctors a form to fill out for testing strips and as long as it's done correctly and accepted by our billing department, the Rx is filled for a very low copay (oftentimes $0 if the patient has a supplemental plan). Needless to say, these Rxs are expensive and time-consuming, so is the effort really worth it?

If pharmacies really are losing $ on these Rxs, why doesn't corporate just make a policy to just outright deny them? Note: filling the patient's other drugs is not a good answer to this last question, because quite a few patients use our pharmacy just to fill Part B scripts only.

Insight is appreciated-- especially if you have knowledge of what goes on behind the scenes (i.e. actual cost to the pharmacy to order these products and the actual reimbursement rates themselves). Thanks!

They bill based off a different system (HCPCS) that you wouldn’t understand.

Based off that system, a box of 100 test strips get converted to (1 test strip) so Med B reimburses less than a dollar all together for 100 test strips that costs around 150$.

For nebulizers, new solutions, and transplant meds, the reimbursement is quite good but the documentation and legal requirements required when filling those scripts are insane.

You basically have to get the doctor to send an e script with icd 10 code included (no oral scripts), document stuff like what model neb the patients has, Insulin, non insulin dependent, first second fill for transplants, AOB forms, no deliveries, making sure you are billing on the day patients PU, etc

Short answer, not worth the headache and big money loser esp after audit claw backs. I know of one customer who fill 1200 test strips a month... and cvs would end up losing about 1800 every month on the script.

Keep in mind, test strips are usually money losers with any insurance but with Med B, WE ARE REALLY LOSING!

 

[Sine Cura]

I thought testing 14 times a day was fake... lol @ 1200/month

 

[MilknCheerios]

Keep in mind, test strips are usually money losers with any insurance but with Med B, WE ARE REALLY LOSING!

If I may ask: where did you find this information out and how certain are you of the source?

But, yes, this is essentially my grievance. The pharmacy team works harder on these scripts only to lose money. If this is the case, why should I devote more energy/time to these scripts? If they aren't ready (on purpose) and the patient is upset and I suggest another pharmacy that may be able to do it... won't I actually be saving the pharmacy money by getting rid of them?

 

[brbi]

I'm not that familiar with how Walgreens operates, but with our independent pharmacy system we are unable to bill Part B through our pharmacy software - I am sure some others offer it but ours does not. We instead have set up a Part B billing program and bill all Part B claims through it - we use Brightree for that and the system is fantastic, however it is extremely difficult for beginners to learn.

A lot of the Part B claims do not reimburse very well and in fact many are, as others have stated, net losses. We do this primarily because other pharmacies will not do it, so we take full advantage of every program we are able to (rebate programs from manufacturers for example) in order to make it profitable. We do a lot of DME rentals and sales so it is easily worth it for us. If we were not providing DME and were strictly providing Part B medications as part of only retail pharmacy, I'd imagine it would be a big time loser and/or it would be consuming far too much time to make it profitable.

 

[MilknCheerios]

@brbi Thanks for the independent point of view. As noted by the lack of available information, chain pharmacies do not disclose to their staff how much of a loss those scripts actually are as they are primary handled by a corporate 3rd party. Still, I suspect they've found ways to make it profitable as well through behind the scenes deals with the manufacturer or bulk purchases through the wholesaler or we wouldn't be doing them either. It just makes me cringe though, when I see a patient's profile and all they get from is is their Part B products and another pharmacy is getting their easy, Part D drugs.

 

[brbi]

It just makes me cringe though, when I see a patient's profile and all they get from is is their Part B products and another pharmacy is getting their easy, Part D drugs.

I definitely feel that pain sometimes!

 

[Aznfarmerboi]

If I may ask: where did you find this information out and how certain are you of the source?

But, yes, this is essentially my grievance. The pharmacy team works harder on these scripts only to lose money. If this is the case, why should I devote more energy/time to these scripts? If they aren't ready (on purpose) and the patient is upset and I suggest another pharmacy that may be able to do it... won't I actually be saving the pharmacy money by getting rid of them?

I can bill for them... so I know what reimbursement are.