Refusing to fill a prescription

[ZakMeister]

Can you actually tell a patient who has caremark or optum or any other medicare plan that you can’t fill their prescriptions due to negative reimbursement or that they are not compliant? I heard it may be a breach of contract.

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[Dred Pirate]

I am not an expert in this area by any means, but I think if you sign up for the contract, you are obligated to fulfill your duty.

 

[Sugoi Travis]

I wouldn't even think about telling a patient that.

 

[owlegrad]

Would you really refuse to fill a prescription due to not being compliant? That certainly won't help their compliance lol

I have never read an insurance contract so I don't know the answer for sure but my understanding is you are required to fill the script per contract. The real question in my mind is would you REALLY tell a patient you won't fill their script because you will lose money if you do? I think that sounds like a great way to lose business to me. I hope they don't fill any profitable scripts at your pharmacy if you are going to run them off that way.

 

[JustFillIt]

I used to manage a super busy retail pharmacy and we would occasionally get what our company called, “low pays”. Essentially what this was is if we filled the Rx we would actually take a financial loss in the dispensing process. Some of these low pays were in excess of 1000 dollars.

Our company decided to crack down on low pays and crack the whip on the pharmacy manager to curb these losses. We were threatened with disciplinary action if we caused losses due to low pays.

We ruminated on what the solution to the problem was. I’m the end there was only one solution - this solution was to fill the Rx somewhere else. What a freaking mess this caused. It’s ridiculous that the corporate office would threaten the livelihood of pharmacy managers due to a screw up on their end.

Anyways - refusing to fill due to “non-compliance”? That is just weird and I can not think of a scenario where this would be reasonable.

 

[Dred Pirate]

Anyways - refusing to fill due to “non-compliance”? That is just weird and I can not think of a scenario where this would be reasonable.

I am trying to think of an issue where non-compliance (I guess partial compliance? would be worse that straight up not taking a med).
Maybe with HIV meds? taking half of your regimen can lead to increased resistance, so you are better not taking anything maybe?

but that is a stretch I admit.

warfarin could fall into this category as well maybe

 

[Sine Cura]

FIlling lamotrigine 200 mg 1 bid when there is no sign pt has picked up in over 6 months.

 

[lord999]

Would you really refuse to fill a prescription due to not being compliant? That certainly won't help their compliance lol

I have never read an insurance contract so I don't know the answer for sure but my understanding is you are required to fill the script per contract. The real question in my mind is would you REALLY tell a patient you won't fill their script because you will lose money if you do? I think that sounds like a great way to lose business to me. I hope they don't fill any profitable scripts at your pharmacy if you are going to run them off that way.

Yes, you would. The NTI's and oral steroids come to mind (warfarin, dig, theophylline, thyroid, long-term prednisone or dexamethasone) as without labs, taking them from a cold turkey noncompliance is not great. But yeah, why they pay us the big bucks for judgment. Most drugs, you're right, who cares?

Insurance contracts have specific clauses (and it's boilerplate language that has been tested) about the all-or-nothing proposition. You take all the formulary or none of it in most cases. Insurance contracts also have boilerplate language about availability and stock outs such that you can't get around it by not stocking the drug in question. (Incidentally, if you run too low an inventory, you do get dinged by insurance companies for partials.) Medicare and Medicaid originate that language and it's just copied.

Also, in most states, refusing this on purely insurance grounds when this is "covered" is going to get the pharmacy before the Insurance Commission, which is disciplinary against the pharmacy. You don't want that. It's different if it's not covered or you're not getting paid, but to deny something that is contractually bound to be honored is considered the insurance version of "bad faith" and has according issues.

 

[BenJammin]

Would you really refuse to fill a prescription due to not being compliant? That certainly won't help their compliance lol

I have never read an insurance contract so I don't know the answer for sure but my understanding is you are required to fill the script per contract. The real question in my mind is would you REALLY tell a patient you won't fill their script because you will lose money if you do? I think that sounds like a great way to lose business to me. I hope they don't fill any profitable scripts at your pharmacy if you are going to run them off that way.

Technically that's not our problem, that's the insurance company's problem since they're the ones on the hook for medical bills if the patient isn't compliant. Every pharmacy that accepts Medicare is graded on med compliance and it affects reimbursements. This is why "medication synchronization" is such a big deal in retail pharmacy. When a patient picks up their 30 day refills on day 50 rather than day 30 they're costing you money. Ideally those patients who don't listen to you or refuse to sync up go somewhere else. Probably not a good idea to tell them to pound sand but that's the ultimate goal. Take your meds like you're supposed to or find another pharmacy.

 

[owlegrad]

Technically that's not our problem, that's the insurance company's problem since they're the ones on the hook for medical bills if the patient isn't compliant. Every pharmacy that accepts Medicare is graded on med compliance and it affects reimbursements. This is why "medication synchronization" is such a big deal in retail pharmacy. When a patient picks up their 30 day refills on day 50 rather than day 30 they're costing you money. Ideally those patients who don't listen to you or refuse to sync up go somewhere else. Probably not a good idea to tell them to pound sand but that's the ultimate goal. Take your meds like you're supposed to or find another pharmacy.

I am aware of that but what I cannot imagine is refusing to fill because the patient isn’t compliant enough. To each their own but holy moly that seems like poor form to me.

Not to mention do you actually lose more money from the noncompliance as you do from not filling the script at all? Even if you do I just can’t imagine telling someone they are “too late” to get a refill and they will have to take their script elsewhere.

 

[zelman]

I am aware of that but what I cannot imagine is refusing to fill because the patient isn’t compliant enough. To each their own but holy moly that seems like poor form to me.

Not to mention do you actually lose more money from the noncompliance as you do from not filling the script at all? Even if you do I just can’t imagine telling someone they are “too late” to get a refill and they will have to take their script elsewhere.

Medication adherence is calculated in aggregate. If you have 10 Humana Medicare patients and 8 of them fill their $5 Lisinopril often enough to take it 79% of the time, but those last two take $100 Telmisartan with perfect adherence, your reimbursement will drop for all ten patients.

 

[MilknCheerios]

If you work for an independent and you don't care about lying, just say you do not have the medication on hand to dispense and offer to call around to places that have it. That way, you provide customer service and preserve your business. If your staff gives you a look, you can explain to them that it was for the bottom line and hopefully they'll understand.

If you work for a chain pharmacy, I would go ahead and fill it because it isn't your money on the line.

Kind of on the topic of reimbursement though - Pharmacy reimbursement rates that hinge on patient outcomes sounds great on paper but incredibly horrid in practice. There are a superabundant amount of reasons why a patient doesn't fill their medication as often as they should and I won't even bother listing them here, but it's almost incomprehensible that the pharmacy be the one to take a hit.

Cutting insurance out and subsidizing drug costs seems like the greener pasture some days.

 

[Sabril]

just told a patient I can't fill a 30 days of synthroid brand for her because we can't get stuck with a partial bottle, especially if her dose will change. We just have to learn how to talk to people to not get in deep $%!#. Unfortunately we are hired to be storekeepers, not patient advocates.

 

[zelman]

just told a patient I can't fill a 30 days of synthroid brand for her because we can't get stuck with a partial bottle, especially if her dose will change. We just have to learn how to talk to people to not get in deep $%!#. Unfortunately we are hired to be storekeepers, not patient advocates.

Convince them to switch to Tirosint next time.

 

[PikminOC]

Convince them to switch to Tirosint next time.

Or armour thyroid. Lol

 

[johnpharm01]

just told a patient I can't fill a 30 days of synthroid brand for her because we can't get stuck with a partial bottle, especially if her dose will change. We just have to learn how to talk to people to not get in deep $%!#. Unfortunately we are hired to be storekeepers, not patient advocates.

That's being cheap. What's the expiration date on the bottle of Synthroid? Can you refuse to fill a prescription with negative reimbursement? Yes. Have I seen it get done? Yes. The real question is will there be consequences? Maybe. You might lose a customer but I see a lot of people use multiple pharmacies. I would consider it a long shot that the insurer comes back at you or the insurance board somehow disciplines the pharmacy or pharmacist. But the certain thing is you will lose money on the rx.

 

[Old Timer]

Can you actually tell a patient who has caremark or optum or any other medicare plan that you can’t fill their prescriptions due to negative reimbursement or that they are not compliant? I heard it may be a breach of contract.

Of course you can't. But It could be out of stock.

 

[Wickett]

just told a patient I can't fill a 30 days of synthroid brand for her because we can't get stuck with a partial bottle, especially if her dose will change. We just have to learn how to talk to people to not get in deep $%!#. Unfortunately we are hired to be storekeepers, not patient advocates.

How slow is your pharmacy that a 90 count bottle of synthroid would be in danger if expiring?

 

[johnpharm01]

That's the oldest excuse in the book. And weak.

 

[Sine Cura]

I don't see what the actual problem is in telling people something is literally not covered if you're eating a nominal 1k+ loss on a dispensing when it would take years for any action to take place and if you work for a chain you'd prob be out of a job by then.

So I am not versed in reimbursement aspects but let me indulge in my ignorance. For example, brand Abilify and Risperdal are officially not excluded NDCs (the actual contract drug list doesn't list what NDCS are covered) for Medi-Cal billing but reimbursement is at generic NADAC, so you'd willingly take a $950-$1050 hit for no reason? Pharmacies should not be in the business of indulging hypochondriacs. At best I MIGHT be willing to get the authorized generic (do you see how health care in the U.S. is a ****ing joke?)

Hell even an independent in my "area" (loosely defined since it's still 3.5 miles away) turned away an expensive seizure med ($6k nominal) we ended up taking (boosting "specialty numbers" amirite) since they didn't want to waste their time with a TAR for **** reimbursement (they don't do Part B either) so "go somewhere else" is what people end up doing anyway

 

[farmadiazepine]

If you get low reimbursement, just tell them you don’t have the drug and are unable to obtain it. Tell them they should get it filled somewhere else and if anything changes you will call them.