Walgreens paying $209M settlement for Not Opening Insulin Pen Boxes

[Heroic Combo]

Looks like this should clear up any confusion.. lol

Walgreens to pay $269 million on claims it overcharged federal programs
Wall Street Journal (01/23/19) Thomas, Patrick

Walgreens Boots Alliance has agreed to pay more than $269 million to settle federal and state lawsuits that accused it of overbilling federal health care programs. Two separate settlements involving Walgreens were unsealed Tuesday in which the company accepted responsibility for conduct the government alleged in complaints under the False Claims Act. The settlements were approved last week by U.S. District Court judges in Manhattan. In the first settlement, Walgreens agreed to pay $209.2 million to the U.S. and several state governments for improperly billing Medicare, Medicaid, and other programs for hundreds of thousands of insulin pens it dispensed to program beneficiaries who did not need them. Federal prosecutors said Walgreens configured its electronic pharmacy management system to prevent its pharmacists from dispensing less than a full box of five insulin pens, even when patients did not need that much. In the second settlement, Walgreens agreed to pay $60 million to settle claims that it overbilled Medicaid by failing to disclose and charge the lower drug prices it offered the public through a discount program. "Walgreens is pleased to have resolved these matters with the Department of Justice," the company said in a statement, adding it cooperated with the government's investigation and has admitted no wrongdoing.

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[footfairy]

I wonder if the documents are still on their intranet from Caremark PBM saying that we aren't suppose to open boxes.

This seems so surreal and to me a bit terrifying. As we move closer and closer to single payer are we going to see more of this? The government couldn't have clarified that they wanted insulin pens dispensed individually to Walgreens years ago? I guess there isn't 200+ million in revenue to clawback into the Medicare coffers if you are upfront about these things though.

 

[mentos]

Wouldn't every pharmacy chain have to pay then?

 

[HandsomeVampire]

I believed every other insurance audits have never depute over un-open box of insulin unless the day supply was completely wrong.
I feel like this have been the case for a long time. Why now?

 

[josh6718]

Waiting for lnsean to jump back in and start this debate again. And no, I still only have a single account 🤣

 

[Timbo]

On the box it says "for single patient use only" though

 

[Sine Cura]

This is hilarious.

As long as you aren't dispensing a full box meant to be up to a 90 day supply every 30 days I don't see what the problem in keeping boxes intact is. (This requires people actually paying attention and training customers not to call it in every 30 days or do auto-fill).

If you have to break boxes, typically it's the commercial customers who will be pissed as they may have been accustomed to getting a full box but the co-pay won't change with a partial box.

 

[CetiAlphaFive]

Waiting for lnsean to jump back in and start this debate again. And no, I still only have a single account 🤣

Muh inbusdry stangdards

 

[Dred Pirate]

I hope somebody got a whistle blower settlement - 10% of that would be nice ass retirement plan

 

[BenJammin]

Insulin pens should not be broken

 

[CetiAlphaFive]

Insulin pens should not be broken

I can't wait for Medicare to sue CVS for not squirting 77 units into a TB syringe.

 

[lord999]

I hope somebody got a whistle blower settlement - 10% of that would be nice ass retirement plan

Four someones did, and 2.5% is enough to retire on. And, we had CRW dead to rights on the matter as the old WHI VP left a hell of a paper trail which got her placed on the exclusionary list. Walgreens had to settle or they would have landed on the exclusionary list.

 

[RxPreceptor]

FDA Drug Safety Communication: FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients
Some source of confusion with the box labeling; intention was to not reuse individual pens
Reading is fun

 

[PieRoller]

To me the packaging implies that the product is meant to be dispensed as a sealed box. There is information on (and in)the box for the patient that does not appear on the individual pen. It should be no more than a days supply issue, and any PBM should be required to accommodate as long as the submitted days supply is accurate.

 

[BidingMyTime]

So Walgreens was fined for not breaking up insulin pen boxes? My understanding was not to break up the boxes, but I remember being a minority viewpoint in that previous long thread. I guess I was completely wrong. :/

 

[owlegrad]

So Walgreens was fined for not breaking up insulin pen boxes? My understanding was not to break up the boxes, but I remember being a minority viewpoint in that previous long thread. I guess I was completely wrong. :/

You and me both!


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[Lnsean]

Waiting for lnsean to jump back in and start this debate again. And no, I still only have a single account 🤣

Nothing wrong. Industry standards and consensus change all the time. It was industry standard to not break them, so I did not. Now that the insurers want us to break them, then I'll break them. I said in the original thread that if they came back and told me to break them, then I would. Pretty simple. All the times that I've been PIC and talked to auditors, no one had an issue with it. This is just a money grab by insurers.

And like the other poster above said, this is all really just about a day supply issue and insurer clawback.

 

[SoylentGreen]

A year or so ago Walmart told its pharmacists to break the boxes. Now I see why.

 

[projektreverb]

On the next Walgreens conference call: “Wages will be frozen in 2020”

 

[Subvisual]

Walgreens' problem was that they were billing the lesser day supply, but also continuously refilling based on that lesser day supply. The lawsuit details how patients would be dispensed enough insulin over 3 months to actually last them 9 months etc. They also sent out automatic refill reminders to patients based on the lesser day supply. Thus making it a clear case of overuse.

There's no indication that it's incorrect to dispense full boxes, as long as you also space out future refills appropriate to the actual day supply.

 

[Dr Wario]

If you cannot break boxes per manufacturer directions, why would the onus be on the pharmacy to make sure patients did not fill too early when the insurance forces restricted day supplies? I don't understand why CVS has not put out a statement on this as of yet.

 

[owlegrad]

If you cannot break boxes per manufacturer directions,...

False, as noted above with a link to the FDA article about that specific issue.

 

[lord999]

FDA Drug Safety Communication: FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients
Some source of confusion with the box labeling; intention was to not reuse individual pens
Reading is fun

God, I actually know the numbskull who wrote that. Glad to know they promoted him to a job where he's oversight rather than writing this stuff.

 

[Lnsean]

Walgreens' problem was that they were billing the lesser day supply, but also continuously refilling based on that lesser day supply. The lawsuit details how patients would be dispensed enough insulin over 3 months to actually last them 9 months etc. They also sent out automatic refill reminders to patients based on the lesser day supply. Thus making it a clear case of overuse.

There's no indication that it's incorrect to dispense full boxes, as long as you also space out future refills appropriate to the actual day supply.

It's weird cuz I was just talking to the CVS in my area the other day...they're still not breaking boxes and they're fine. I think it has to do with how Walgreens did it.

 

[radio frequency]

I’ve never actually seen a pharmacist break a box of insulin in person. It’s one of those unicorn events I’ve only read about online.

 

[Dr Wario]

False, as noted above with a link to the FDA article about that specific issue.

Ok fine, but were this an actual issue CVS would have sent out mass messaging and mandatory unpaid meetings by now.

 

[lord999]

It's weird cuz I was just talking to the CVS in my area the other day...they're still not breaking boxes and they're fine. I think it has to do with how Walgreens did it.

Yeah, the nuance isn't about not breaking the boxes alone, that's actually ok. The nuance was getting the days supply correct if you didn't break the boxes that the patient doesn't build up a stockpile. Otherwise, you're supposed to dispense less than 30 days or the minimum quantity. The problem with Walgreens is that they internally understood and directed pharmacists to overbill, that's what they really got nailed for.

 

[Sparda29]

Say that the dose is 20 units daily. 1500 units/box / 20 units = 75 day supply

Say the patient's insurance only covers 30 days at a time, if you dispense 1 box, you simply do not refill it until 75 days and you're good? Or dispense 2 pens every 30 days?

 

[Subvisual]

Say that the dose is 20 units daily. 1500 units/box / 20 units = 75 day supply

Say the patient's insurance only covers 30 days at a time, if you dispense 1 box, you simply do not refill it until 75 days and you're good? Or dispense 2 pens every 30 days?

That is the question at the heart of this. My pharmacy fills only in full boxes and hasn't yet been dinged for it on an audit. I'm reaching out to my state's Medicaid program just to confirm that they're not completely opposed to this practice (not that they'll likely give me a straight answer either way).

 

[bacillus1]

Say that the dose is 20 units daily. 1500 units/box / 20 units = 75 day supply

Say the patient's insurance only covers 30 days at a time, if you dispense 1 box, you simply do not refill it until 75 days and you're good? Or dispense 2 pens every 30 days?

Also don't forget to add 2 units per injection for the safety test. Hopefully insurance companies remember that as well.

 

[Thoughtfulsinner]

I’ve never actually seen a pharmacist break a box of insulin in person. It’s one of those unicorn events I’ve only read about online.

This. Never seen anyone break a box of insulin.

 

[lord999]

Say that the dose is 20 units daily. 1500 units/box / 20 units = 75 day supply

Say the patient's insurance only covers 30 days at a time, if you dispense 1 box, you simply do not refill it until 75 days and you're good? Or dispense 2 pens every 30 days?

Pretty much, but that's contract specific. The problem is exactly with someone writing in such a way that the quality dispensed always is more than 30 days.

 

[WorthlessOxygen]

Say that the dose is 20 units daily. 1500 units/box / 20 units = 75 day supply

Say the patient's insurance only covers 30 days at a time, if you dispense 1 box, you simply do not refill it until 75 days and you're good? Or dispense 2 pens every 30 days?

I would give out 2 pens as a 30 day supply. I get that you can manually keep track of the actual days supply and just not fill early but I don't understand why you'd make that much extra work for yourself. It's not like you would dispense a whole 100 count stock bottle of something like lisinopril instead of 30.

Also don't forget to add 2 units per injection for the safety test. Hopefully insurance companies remember that as well.

I was always told that there's overfill in the pens to correct for this. It was actually a counseling point that my school had in one of our practicals. The pharmacies I've worked at have never added this priming dose and as far as I can tell there haven't been issues with it.

 

[Thoughtfulsinner]

I would give out 2 pens as a 30 day supply. I get that you can manually keep track of the actual days supply and just not fill early but I don't understand why you'd make that much extra work for yourself. It's not like you would dispense a whole 100 count stock bottle of something like lisinopril instead of 30.I was always told that there's overfill in the pens to correct for this. It was actually a counseling point that my school had in one of our practicals. The pharmacies I've worked at have never added this priming dose and as far as I can tell there haven't been issues with it.

This is correct

 

[Sparda29]

My biggest issue with giving out pens instead of boxes is that it triggers my OCD for labels. It's practically impossible to put a standard pharmacy label on a pen without folding it or making it look like ass.

I went off on a tech one time because he constantly put labels crooked. "My dude can you put the labels on the bottle or box straight? Is your dick crooked or something that you're off balance and can't put a label on straight?"

 

[Subvisual]

I was always told that there's overfill in the pens to correct for this. It was actually a counseling point that my school had in one of our practicals. The pharmacies I've worked at have never added this priming dose and as far as I can tell there haven't been issues with it.

I'm sure they say that, but realistically how would that be possible? Adding 2 units to the 60 lantus you inject daily would be negligible overall. Adding 2 priming units to your 2 units of sliding scale short acting insulin would effectively double your insulin usage though. The effect of priming would scale dramatically based on the size of the individual doses.

 

[WorthlessOxygen]

I'm sure they say that, but realistically how would that be possible? Adding 2 units to the 60 lantus you inject daily would be negligible overall. Adding 2 priming units to your 2 units of sliding scale short acting insulin would effectively double your insulin usage though. The effect of priming would scale dramatically based on the size of the individual doses.

Using 2 units per injection would mean that the pen would pass it's BUD before running out, even with priming doses.

Without doing the math, I don't think it's unreasonable to base the overfill on minimum dose used to finish the pen before the BUD then adding enough to cover priming based off that dosing schedule. But I honestly don't know.

More importantly, I've never met a pharmacist that accounts for priming in the days supply and my school is actively teaching pharmacists not to. I haven't heard of issues with people running out too soon so I can't imagine that there are too many problems with counting days supply this way.

 

[Subvisual]

Far be it from me to suggest a member of pharmacy academia may be lacking in real world experience or problem solving skills.

Say a patient is injecting 4 units TID. That would be 12 units/day. 300 units per pen means we would expect each pen to last the patient 25 days.

If they prime with 2 units at each dose now they're using 18 units/day. Now each 300 unit pen would expected to last 16 days. That's quite a discrepancy, no? Well outside the 75% usage window that most PBMs would allow for an early refill, so you would run into issues with the patient running out early.

 

[bacillus1]

This is correct

Good to know. We all add the 2 units...but it's not like the VA religiously tracks days supply for most things since we are the prescriber, dispenser and insurer.

 

[WorthlessOxygen]

Far be it from me to suggest a member of pharmacy academia may be lacking in real world experience or problem solving skills.

Say a patient is injecting 4 units TID. That would be 12 units/day. 300 units per pen means we would expect each pen to last the patient 25 days.

If they prime with 2 units at each dose now they're using 18 units/day. Now each 300 unit pen would expected to last 16 days. That's quite a discrepancy, no? Well outside the 75% usage window that most PBMs would allow for an early refill, so you would run into issues with the patient running out early.

Fair enough. Since you didn't really mention the 20% overfill I'll assume you don't think it's too unreasonable so I'll continue using it for now. That would stretch the pen to last 20 days, or 80% of what was expected: safely past the 75% cutoff mentioned. Just to reiterate I really don't know if it's actually a reasonable amount though and I'm not entirely sure how to find out.

As for the academia dig, I definitely get it and take everything taught with a grain of salt. But to emphasize, every pharmacist I've worked with has not included priming units in the days supply and I haven't had patients running out early when using as instructed.

 

[Rxaunt]

I no longer work for Walgreens but I believe they have been breaking insulin pen boxes for about a year. When they started it there was a newletter saying basically failure to break them to match days supply could/would(?) result in termination. So yeah we broke boxes the individual pens are then put into a zipper baggie. And yeah it sucked I was so glad when I left I didnt have to do that anymore because basically every time i checked an insulin I would cover my butt writing on the monohraph the math that said how many pens because patients would argue they were shorted. Then i knew i had proof I was right. The only good outcome from breaking a box possibly can be when a patient can't afford the whole box then you can dispense them a single pen.

 

[Mr. Corporate Pharmacist]

I always break the insulin boxes because I dont have time to monitor every single auto fill.

There's nothing wrong with breaking boxes, and it's easier to keep track of subsequent fills.

I would argue that most pharmacists are too busy to worry about overbilling issues. So many claims are being over billed.

How many pharmacists actually knows what their Third Party reimbursement losses are?

I know my P&L, but I still dont have access to the exact breakdown. We have a whole third party department that monitors and fixes all these for us.

Whether you break boxes or not, you're in charge of ensuring you don't lose money from insurance companies.

They literally have teams of people who have quotas for how much money they take back from pharmacies.

Why give them an excuse?

I say break the box and explain to the patient how to use their insulin appropriately to last the billed day supply

 

[sozetone]

Looks like this should clear up any confusion.. lol

Walgreens to pay $269 million on claims it overcharged federal programs
Wall Street Journal (01/23/19) Thomas, Patrick

Walgreens Boots Alliance has agreed to pay more than $269 million to settle federal and state lawsuits that accused it of overbilling federal health care programs. Two separate settlements involving Walgreens were unsealed Tuesday in which the company accepted responsibility for conduct the government alleged in complaints under the False Claims Act. The settlements were approved last week by U.S. District Court judges in Manhattan. In the first settlement, Walgreens agreed to pay $209.2 million to the U.S. and several state governments for improperly billing Medicare, Medicaid, and other programs for hundreds of thousands of insulin pens it dispensed to program beneficiaries who did not need them. Federal prosecutors said Walgreens configured its electronic pharmacy management system to prevent its pharmacists from dispensing less than a full box of five insulin pens, even when patients did not need that much. In the second settlement, Walgreens agreed to pay $60 million to settle claims that it overbilled Medicaid by failing to disclose and charge the lower drug prices it offered the public through a discount program. "Walgreens is pleased to have resolved these matters with the Department of Justice," the company said in a statement, adding it cooperated with the government's investigation and has admitted no wrongdoing.

Yeah we at WM just started breaking pens into plastic baggies!...lol. looks horrible, but technically, the days supply did not match, so yeah it's fraud. Many people were getting more than they needed ya know? During a time when Gov't is trying to reduce healthcare costs , this wont stand. It sucks, but i would start doing it if you are a store Manager, and pronto.

 

[zelman]

JFC. They changed their GD minds.

https://www.votervoice.net/BroadcastLinks/XqseEEs5PlEINxNqHjmyzA

 

[Sine Cura]

Noting the day supply in the sig is not a bad idea (inb4 'practicing medicine w/o a license')

 

[MilknCheerios]

Is it a bad thing that it took me forever to even find out that PAAS stands for pharmacy audit assistance service? Well, I haven't noticed many chargebacks for breaking insulin pen cartons, but then again, I work for a chain so who knows how many chargebacks I don't see. Unless my chain updates their guidelines, we will continue to break'em if we have to.

 

[Sine Cura]

I saw a recoupment once from CVS Caremark for auto-filling Freestyle lancets. FTW!

 

[owlegrad]

JFC. They changed their GD minds.

https://www.votervoice.net/BroadcastLinks/XqseEEs5PlEINxNqHjmyzA

Interesting. Seems like vindication for certain people.

I guess this means a new (old) “industry standard”?

 

[angelsplight]

Insulin is such a PITA now because I'm getting fax every once in a while now from an ins auditing an insulin fill. Of course they dont get any of it back but its annoying. I became stingy of the insulin supplies too if someone is using a box of lancets for qd but we gave to bill for 30 days not letting it go through unless its been like 80ish days because I know its another audit waiting to happen with how unusually well it pays.

 

[confettiflyer]

We have a pharmacist in our endo clinic and she purposefully makes the sig “inject UP TO xxx units per day” to provide cover for non fixed dose short acting insulin.

Any other advice I can disseminate?


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