Waiving medicare a-d copays?

[Charcoales]

Floated to a store. Patient comes in saying they can't afford their medicare copay. I said we can't waive medicare co-pays. Patient says we waive/pay them all the time for them and that if we don't waive it they'd report me... I said I'd have to verify if we can waive medicare co-pays with another pharmacist since there were no notes in the system that we could...

I thought that was only possible for state medicaid insurances to do IOUs or waiving them for inability to pay, never heard of this for medicare insurances.

Would it be unethical/illegal if I just gave them the 50 cents for the copay just to get them out of my hair?

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[Abby Atwood]

It's actually okay to reduce patient cost sharing due to recent updates to the anti-kickback statute safe harbors. Pharmacies may reduce patient cost sharing for Medicare patients similar to how provider offices could reduce patient cost sharing. Changing cost sharing is only appropriate if:

(1) The waiver or reduction is not advertised or part of a solicitation;
(2) the pharmacy does not routinely waive or reduce the cost-sharing; and
(3) before waiving or reducing the costsharing, the pharmacy either determines in good faith that the beneficiary is in financial need or the pharmacy fails to collect the cost-sharing amount after making a reasonable effort to do so.

https://www.gpo.gov/fdsys/pkg/FR-2016-12-07/pdf/2016-28297.pdf

 

[zelman]

It's actually okay to reduce patient cost sharing due to recent updates to the anti-kickback statute safe harbors. Pharmacies may reduce patient cost sharing for Medicare patients similar to how provider offices could reduce patient cost sharing. Changing cost sharing is only appropriate if:

Is this accounted for in pharmacy contracts with the PBMs who administer the part C/D plans?

 

[Sine Cura]

Yes... the "all the time" excuse that people pull out of their asses

If they are dual eligible you could split bill Medicare and Medicaid.

 

[quickpic007]

Floated to a store. Patient comes in saying they can't afford their medicare copay. I said we can't waive medicare co-pays. Patient says we waive/pay them all the time for them and that if we don't waive it they'd report me... I said I'd have to verify if we can waive medicare co-pays with another pharmacist since there were no notes in the system that we could...

I thought that was only possible for state medicaid insurances to do IOUs or waiving them for inability to pay, never heard of this for medicare insurances.

Would it be unethical/illegal if I just gave them the 50 cents for the copay just to get them out of my hair?

This is the saddest thing I would see in a previous store. People complaining they cant afford less than $10, especially the elderly. Makes me wonder if they ever worked a day in their entire life, or were hit by financial ruin some other way.

 

[Abby Atwood]

Is this accounted for in pharmacy contracts with the PBMs who administer the part C/D plans?

I think it does, but I'm not entirely sure. I'm not an expert by any means.

 

[Charcoales]

Just necroing this thread to see if anyone else knows for sure if u can waive. Happened again today, swore they couldn't afford their partD copay and demanded we waive it because they said they'd get sick and die if we didn't give them their medication...??? I told them we can't waive and your insurance says you're responsible for the copay and they're saving you several hundred dollars off the cash price... I dunno...

 

[PharmacistFl12]

Read your company policy carefully. For my company, price modifying a copay is considered insurance fraud and your employment will be immediately terminated.

 

[Sparda29]

I always waive copays.

 

[txpharmguy]

Just necroing this thread to see if anyone else knows for sure if u can waive. Happened again today, swore they couldn't afford their partD copay and demanded we waive it because they said they'd get sick and die if we didn't give them their medication...??? I told them we can't waive and your insurance says you're responsible for the copay and they're saving you several hundred dollars off the cash price... I dunno...

Just tell them you're contractually obligated to collect the copay on part D. If they can't afford to it, they should contact Social Security on their iPhone X and apply for additional assistance

 

[johnpharm01]

Read your company policy carefully. For my company, price modifying a copay is considered insurance fraud and your employment will be immediately terminated.

How is modifying a copay fraud?

 

[PharmacistFl12]

How is modifying a copay fraud?

If you modify a medicare Part D copay, it is considered Medicare fraud. According to my company, it is automatic termination of employment if you price modify any copay. Do a quick google search about price modyfing copay and insurance fraud. Copay is considered a contract between patient, pharmacy and payor (insurance). Intentionally modyfing a copay especially federal plans is illegal.

 

[PharmacistFl12]

You break 2 laws by price modyfing a copay. In regards to Medicare, you're violating patient inducement and anti-kickback laws. For example, let's say Pharmacy A decides to wave at $3 copay for a drug while getting reimbursed $600 for cost of medicine. Pharmacy B, still charges that $3 copay. That patient might have more incentive to go to Pharmacy A. This is why Medicare does not allow these types of illegal acts, like giving out gift cards etc. to a Medicare patient for filling at your pharmacy.

 

[johnpharm01]

You break 2 laws by price modyfing a copay. In regards to Medicare, you're violating patient inducement and anti-kickback laws. For example, let's say Pharmacy A decides to wave at $3 copay for a drug while getting reimbursed $600 for cost of medicine. Pharmacy B, still charges that $3 copay. That patient might have more incentive to go to Pharmacy A. This is why Medicare does not allow these types of illegal acts, like giving out gift cards etc. to a Medicare patient for filling at your pharmacy.

Thank for the explanation that makes sense. But for a MEDICAID copay where the customer requests it are you allowed to modify a copay. This is required by law.

 

[Charcoales]

Thank for the explanation that makes sense. But for a MEDICAID copay where the customer requests it are you allowed to modify a copay. This is required by law.

Yeah Medicaid you can waive if they swear they have 0 money. Medicare is one I'm not sure about...

 

[johnpharm01]

Yeah Medicaid you can waive if they swear they have 0 money. Medicare is one I'm not sure about...

I think Pharmacistfl12 is right no can do

 

[FinallyOnTrack]

Yes... the "all the time" excuse that people pull out of their asses

If they are dual eligible you could split bill Medicare and Medicaid.

In Florida, dual eligible patients are not split billable.. the way it worked here is that Medicaid determines the level of need the patient has and sets the patients copays accordingly.. if we attempted to bill Medicaid as a secondary, it came back rejected every single time..


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[FinallyOnTrack]

What happens if they are in the GAP / donut hole and they are picking up their lantus - $600 copay - are you going to waive that too??? If so, I’m transferring every diabetic Rx I know up to you and using that excuse (only kidding)..


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[aznsensazn3]

In Michigan per our Pharmacy lawyer, "we must never, ever waive a copayment." In Michigan, for Medicaid patients, if the patient can't pay for their copayment, we can't refuse to dispense the prescription, but they technically still owe us the copayment and is considered a debt. I agree with the pharmacistfi12 with Medicare patients. Considered a kickback if a copay is waived. Not much different than giving a patient a coupon or gift card to use a particular pharmacy which is a big no no for government plans. Best thing for the patient to do is to fill out information for low income or additional assistance. There's a form online on the social security website called "application for extra help with Medicare prescription drug plan costs" or the patient can visit their local social security office if they need help filling out the application.

 

[zelman]

Thank for the explanation that makes sense. But for a MEDICAID copay where the customer requests it are you allowed to modify a copay. This is required by law.

Technically, you are just required to provide the service regardless of the patient’s ability to pay. That doesn’t mean the copay must be waived. You can continue to request payment.

 

[Sine Cura]

In Florida, dual eligible patients are not split billable.. the way it worked here is that Medicaid determines the level of need the patient has and sets the patients copays accordingly.. if we attempted to bill Medicaid as a secondary, it came back rejected every single time..


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We have one managed care Medicaid plan in California that will cover Medicare copays even if they have Extra Help but you have to call the provider line to request it... every... time. Why it does that compared to the other managed care plans that don't, I do not know. In Arizona we were were also somehow able to get United Healthcare Community Plan to pick up Medicare copays even though CVS is not even contracted with UHC Medicaid (maybe this was a mistake...)

Medicaid only % is 60% and 30% is Medicare and 80% of that 30% have Extra Help so I don't run into complaints about actual copays that often... mainly situations where the pt was previously on Medicaid only then switched to Medicare with Extra Help... yes people bitching about $1.25 and $3.70 copays

As for people claiming they will die... it happens all the time. Who is actually fazed by such complaints... go back to the ED then even though it's a flagrant waste of resources

 

[Ace41690]

My understanding is you can waive the copays as long as the patient is dual eligible (Medicare/Medicaid). You must also make a "good faith effort" to collect the copay. I think there is a way to bill part D copays to Medicaid but I have never seen it done successfully.