How to succeed at retail pharmacy according to the chains

So during my 0.004 second lunch during the clusterfuck of a day after a holiday, I checked out this article on DrugTopics.  Nothing special at face value, however this paragraph really bugged me:

Several factors led Morton’s executives to make the decision to sell most of its retail pharmacy business. “It’s the declining reimbursement environment, mandatory mail-order plans, the closed networks that are starting to become popular across the country, $4 generics programs, and predatory audits,” Morton said.

Both health insurance companies and government programs are slashing reimbursements, according to Morton, a practice that is “not providing enough margins for us to serve patients.” In addition, the purpose of audits conducted by pharmacy benefit managers (PBMs) has changed from detection of fraudulent claims to making extra money for the PBMs, according to Morton. “They are looking for administrative mistakes so they can look to recoup claims. It is a revenue-generating technique,” Morton said.

For those not in the industry, Walgreens has a Pharmacy Benefit Manager called Walgreens Health Initiative.  This is similar to how CVS/Caremark work, and the infamous Merck/Medco.  Now for those of you who work retail, this whole article makes perfect sense.

  1. Have your PBM give ridiculous low reimbursement rates to kill the independents.
  2. Be first in line to “take your failing pharmacy off of your hands for you”
  3. If they refuse, audit the shit out of them for every little fucking thing until you bankrupt them
  4. See step 2
  5. Profit!

Funny, how it’s technically illegal for a bunch of independents to meet to discuss if they are going to take a PBM contract due to antitrust laws, but the major chains and their PBM backers can pull this kind of bullshit.  Of course the major chains can bribe (yes, I said bribe…er.. LOBBY) the corrupt government to look the other way.

Having gone through a dozen+ audits, the article is 100% right.  The auditors aren’t looking for blatant fraud and abuse, they are looking to generate profits.  When you fill an Rx, if you mark a faxed back OK as ‘written’ in your software (instead of a ‘faxed’), that’s grounds for them to take the entire cost of the Rx out of your next check.  I bet, with a bit of digging, you’ll find that these auditors actually get an incentive-pay based upon how many ‘errors’ they find on the pharmacy end.  I will also bet that Caremark doesn’t audit CVS stores, WHI doesn’t audit Walgreens, and Merck doesn’t audit the Medco mail-order chains.  Even if they did audit them, do you really think they would take the money out of their next check? Isn’t that taking money away from themselves?

Sometimes the audits pick up things that are just mistakes, like when you have a Robatussin-DM in your computer as 1 bottle of 273mL and your floater bills 273 bottles by mistake thinking that it’s in the computer as per-cc instead of per-bottle.  Those I can see, but taking back the ENTIRE reimbursement over a 28 day supply vs 30 day supply for eye drops is petty and bullshit.  We have the Rx, its legit, yet you are back-charging us for the entire amount due to a clerical error (and a stupid one at that).  The Rx wasn’t filled fraudulently, and it was filled in good faith with no intent to fraud.  However try to argue this point with the auditors and you’ll just get a blank stare and 100 more ‘errors’ that will make your next reimbursement turn into a bill.

So the million dollar question is: Where is APhA in this mess?

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53 Comments

  1. Magic8ballrph says:

    Amen brother. I have seen this predatory technique at my last place. Even if you can prove (to their standards) that it was filled right, you wasted more than the cost of the Rx in man hours tracking it down. total bullshit. I am the opinion that no pbm, insurance company, or pharmacy SHOULD IN NO FUCKING WAY OWN any percent of each other, AND should remain independant.

  2. SampMan87 says:

    Insurance companies hold all the cards. They call all the shots. They get to decide how much they are going to charge their beneficiaries in premiums, how little they’re going to reimburse the pharmacy, and when a claim is rejected, they don’t have to pay someone to fix it. WE fix it. It’s truly sickening that this fact alone hasn’t violated some kind of anti-trust law already. But now, chain pharmacies are in cahoots with their own PBMs, and with the recent surge of Walgreens Take Care clinics and CVS Minute Clinics, they’ve got all the bases covered. Walk-in clinics, Pharmacy, and Insurance.

    I’ve been an intern at Walgreens for 2 years and a tech for 3 before that. It seems like every day I learn a little more about how the corporate machine works and it’s becoming increasingly disturbing.

    • Ozzie West says:

      Intern??

      You have not yet ditched that to get into a real profession? It is not long before the pharmacist “shortage” turns into an enormous Pharmacist Glut and the chains start paying RPh’s about $12.00 an hour. Hospitals and others will follow suit as soon as they are able to pick and choose from the unemployed RPh pool.

      Oz

      • BandAid4RiteAid says:

        If the pay gets low I’m out of this profession. I am not kidding when I tell you I will gladly wash dishes and be a whole lot happier!

        I can believe some of the new guys just graduating are $230,000.00 in debt with student loans.

        At least I wasn’t that stupid.

        • important says:

          yea it was soooooooooooo fucking haqrd counting all tho pills making the big bucks. Just who do you asshole think your kidding.

  3. Adam says:

    Walgreens spun off WHI a while back. They’re related in name only.

  4. Jeremy says:

    Article is spot-on. PBM’s are going to be the end of us all.

  5. hattric73 says:

    It is obvious that it is a money making scheme.

    1: Why don’t they audit HCTZ or atenolol prescriptions?
    1b: They only audit high $$$ prescriptions
    2: If it is about safety and training, why do they take full reimbursement back on the date of the rx being one day off, or the method of transmission (fax vs written)
    3: I know, for a fact, that at least one company gives the auditors a quota to meet, I don’t know about a commission.

  6. ScottCPhT says:

    As a former WAG employee, they announced about four months ago (or so) that WHI was being spun off from the Walgreen “Family of Companies” which had then included Duane Reade out of New York. The reason was because they found that WHI was no longer being profitable enough to keep in the portfolio, though they made it sound rosier than it did. They sold that part of the business to CatalystRX, which (if I recall correctly) manages other PBMs across the country.

  7. ALLEN says:

    As a Dr. , I will also add, is where are the patients going to get their 30 day RX they need when same damn mail order faxes us for “clarification” when the entire element for the Rx are there? I know exactly what it is. Its a way to delay filling an Rx so some poor guy or gal has to go get a months worth of there med of off their ”book”. saves them 1/12 of the cost of that med for them. Then in a few months I will get some damn fax complaining of the patient ”not filling thier Rx correctly”. no shit. You’re off because they got a stash you cant account for nor paid for. Go to hell mail in Pharm. Still pay a bit more to get mine from my independent pharmacist. Why? because he works for ME, not the PBM, mail order MoFo’s

    • Shell says:

      The damn insurance companies are requiring that all the following is correct: day supply, npi, name on the script is exactly as it is on their insurance card, whether the script was faxed, called, written or electronically sent. ….OTHERWISE they can take back their reimbursement. BY the time you check all the ridiculous crap…you are too damned tired to see if there is an interaction or if you really filled the medication correctly. IS THERE ANYTHING WE CAN DO ABOUT THIS CRAP! I just got audited and they are taking back 3 scripts ($3000) because the NPI was incorrect. Hope they all go to HELL!

      • padenerik says:

        We can ban together as a profession and refuse to accept third party payors or work for any company that does, but that will never happen. Pharmacists don’t care enough about their profession to do that.

  8. Jessica says:

    In Illinois, I know the IPhA is slowly working towards a set of rules that can and cannot justify marking something as fraudulent as there really isn’t one yet. And I have heard that auditors ONLY get paid if they find “mistakes”.

  9. Jane says:

    I had an audit once and the auditor actually told me that if they reach a certain dollar amount they can stop looking. My most recent audit, every script they looked at was for suboxone

  10. CVS Rph says:

    As a CVS pharmacist, I can confirm we actually do get audited by Caremark. It actually seems like they audit us the most. However, we don’t actually give a damn about that audit. The way the pharmacists look at is moving money from the left pocket to the right pocket. We actually think it’s stupid and that the company should just quit making it look like they’re trying to be fair.

    • pill pusher says:

      If a CVS store gets audited doesn’t that count as a loss from that store’s bottom line? So it’s beneficial to them if each individual store can claim those losses at tax time because each store reduces their tax liability with each audit. They would still have to pay the tax on the profit that Caremark makes from those audits but that is only if Caremark makes a profit. I am not an accountant and not exactly sure how they keep their books. Maybe I am off, however, no matter how they do it you can rest assured that auditing themselves makes them more money in the end.

  11. Farm.D says:

    The whole healthcare industry is just another sick convoluted for profit model that serves to help nobody but their shareholders. They would make us work 24 hour shifts with no lunches or breaks if they thought they could get away with it. It’s amazing any human being can survive working retail for over 10 years… Next we will be taking stool samples and doing free (of course) digital rectal exams while simultaneously giving flu shots…. It’s all about patient care right?

  12. Sarah G says:

    You’re assuming that APhA is your friend and not theirs…

  13. Disgusted Pharmacist says:

    I recall when working at WAG when CVS caremark decided to audit them. I particularly found this amusing–the chains are not strictly biased to independents, they will fuck each other over too! I wish all the bastard chains would fall!

  14. Pharmboy says:

    Where is APhA in this mess? Funny, I hear crickets chirping! I dropped my membership a LONG time ago.

    • BandAid4RiteAid says:

      Smart move Pharmboy. It’s a shame other pharmacists don’t have your commonsense. I would have called you a genius if you would have never joined in the first place.

  15. Ozzie West says:

    APhA and the rest of “The Pharmacy Industry Leaders” of the 40’s/50’s/60’s are the ones who first sold the entire profession Down The River, literally to become slaves of the PBM’s and Chain Pharmacy Schucksters. These half-wits are probably all safely dead now. But, we could still find out where they are buried and take an enormous leak on their graves. The guy who signed the first PBM contract should get the most gallons.

    Oz

  16. BigRetail says:

    APhA isn’t involved yet because we own them too…..

    • BandAid4RiteAid says:

      If the big retail chains (CVS, Rite Aid) were walking and came to a sudden stop the face of the APhA would go halfway up their ass.

      • TitsMcGee says:

        Only halfway? You’re too kind. I recently met a wonderful young lady who was all excited about applying for pharmacy school. I hope to God I was successful in talking her out of it (with the help of this blog, of course). I consider it my greatest deed for the year. I’d really hate to see her to completely fuck up her life and join our pitiful ranks.

  17. FML(I,Am,A,Pharm.) says:

    Predatory audits….now that sounds very accurate and now lets continue…

    Predatory customers who want to give you a hard time to get a gift card.
    Predatory corporations that exploit you because after you verify a prescription $ is made
    Predatory government agencies…federal, state, and local…not to mention the special tasks forces of these agencies…that are always willing to breathe down your neck, cut off your head at the glance of something going wrong, and make your career a living hell out of fear from a visit from one of these guys, even if you did nothing wrong.
    Predatory Board of Pharmacy…unelected government bureaucrats appointed by govenors for political reasons that are not held accountable for the rules and regulations that they make do not mix well with pharmacy…not to mention many of these are being over represented by corporations (conflict of interest?) these guys love to fine the shit out of you for nothing and hold your feet to the fire. Maybe the reason the BOP is the MOST corrupt is because they are made up of pharmacists. If all the rules and regulations for pharmacy were a food it would look like a huge plate of spaghetti with a huge piece of shit on top that all pharmacists had to eat.
    Predatory Pharmacy Schools…B.S. of pharmacy, then pharm.d., now required residencies? are these guys ever satisfied…not to mention there are not jobs in pharmacy right now and all these new schools are really throwing the profession out of hell and into the eternal lake of fire. Now we all burn forever.

  18. BandAid4RiteAid says:

    The APhA? What a joke that is. They are the backstabbers that pushed that immunization fiasco on us. I have no time as it is to eat or take a leak and now I have to deal with that nonsense??!! The APhA is bought and paid for by the big chains. They look at what can increase profit, not what’s in the best interest of the pharmacist.

    Any pharmacist that belongs to that outfit is without a doubt the east end of a west-bound horse.

    I pity the wet-behind-the-ears PharmD who calls me to join that idiot organization.

  19. on_the_edge says:

    The auditing game is a game of dollars. PBM’s are tageting software issues as much as anything to take back paid claims. Independents take note. Updating software may well be worth the dollars spent to keep decimals and days supply intact. After much research, I have concluded the following: If you correct these issues the auditors will be left with nothing.

    Correct the billing errors on the follwing meds: Pegasys, Copaxone, PrevPak, Fosamax, Asmanex, vaccines, Aranesp, pack multiples, and days supply entered as one. Basically, the data miners are searching for billing errors involving a mix up of pack size, ml size and days supply.

    If your days supply falls out of normal range than you my friend are up for an audit if the cost of the med generates good dollars back.

    Another sucky part of being a retail pharmacist that makes you have to answer to your supervisor why you let a certain days supply go when in fact the reality is a tech did it and you had no time to verify the info based on time constraints placed on you on just getting the Rx filled. God bless all of you as this job is one of the most trying and yet you can’t get any sympathy or real indepth discussions with people outside of the industry because the average worker can’t relate due to never having experienced the horrors of retail phamacy and the miracles we perform as an individual.

  20. Jenn says:

    I am a former pharmacy tech turned teacher who is working for Kaplan College as instructor (I was laid off as a high school English teacher due to budget cuts). I am searching high and low for a definitive answer to this question; maybe you can help.

    When a days supply does not come out evenly (say 16.5 days) do you round down to 16 or up to 17? I was taught that you round down because the patient only actually a s 16 day supply available to them. Somebody is now saying that is incorrect and insurance companies are requiring you to round up.

    What is your understanding? Are there are any resources you know of that have a definitive answer? Thanks so much.

    • Pharman says:

      ALWAYS round up; you won’t run into trouble w/ ins. cos. Pt.s can always get a refill within one day of days’ supply (ie-RX can be refilled on the 16th day if days’ supply=17).

  21. Nancy Jones says:

    I just wanted to say, though I am not a pharmacist, I enjoy your writing and insight into a world most people know very little about. I also would like to say I am appalled at the way members of your profession are treated. I can hardly believe what I have read. I have never in my life even gotten snippy with any pharmacist, anywhere. I would never consider it- pharmacists are people to be respected, same as an MD. In fact, I’d be quicker to respect the pharmacist, because while I have experienced some truly arrogant, awful MDs, I cannot ever recall ever having an unpleasant incident with a pharmacist. Shame on anyone who does not know how to behave with a pharmacist! And thank you for the job you do.

  22. Disgusted Pharmacist says:

    Oh goody–I’m a genius!

  23. Jeremy T says:

    Where is APhA? Where are they ever? This is such a crap scheme from PBMs and it is very sad that no one in our crap government tries to put a stop to the petty BS. Can we all unite and form a new group to combat this kind of stuff. I’m still looking for my lunch break.

  24. Sojillish says:

    I’ve actually had to sit thru quite a few Walgreens audits… Including WHI. I remember thinking to myself… why is Walgreens wasting money to not pay themselves. A few months later my district position was cut and I was put back in a store to hack things out with the rest of the techs. Apparently this was to save money… like money wasted while WHI audited Walgreens stores. If people up in corporate had any common sense… Well I won’t get into that cause they have spies every where and there goes my hack job.

  25. roundwhitetablet says:

    The Angry Pharmacist, you are correctomondo. These auditing practices are ridiculous. It drives me crazy that I have to watch over these prescription hardcopies like a vulture. Here’s one example of a meritless audit tactic: You receive your refill request back from the doctor’s office via fax and it is signed by the prescriber on the authorized to refill section. However, the prescriber did not write the number of refills authorized. We were charged back the full amount of the claim. We thought that if the prescriber signs his or her name on the “authorized to refill” section of the refill request, this means that he or she is authorizing a refill. Maybe not multiple refills, but at least one. According to the audit, we thought wrong.

    In this case, we would have made more money by not filling this patient’s prescription.

    These audits are supposed to fight fraud, waste and abuse. Instead, some audits, like TAP has referred to, are targeting unsubstantiated instances to generate revenue. It’s a dirty practice, really.

    The ones who set up shop in a garage or basement with only a computer with pharmacy software and a credit card machine are supposed to be the targets of these audits. I would imagine that authorities have already caught all these blatant attempts to steal, but who knows.

    For the people who are trying to earn an honest living, these auditing practices make it such a hassle to practice pharmacy. In school, we are taught that the role of the pharmacist is expanding, but perhaps the field of legal issues might have been underemphasized, or its magnitude of significance may have been overlooked or ignored.

    On another note, my first year after graduating pharmacy school, I tried to renew my APhA membership online, and was unable to submit payment. I figured if they couldn’t handle an online electronic credit card payment, then maybe they didn’t care enough about its membership. I’m sure the site has been fixed since then, but I no longer have a desire to join.

    The Angry Pharmacist, thank you for the insight once again.

  26. RX transfer says:

    We are trying to start a movement to fight the corporate pharmacies – https://www.facebook.com/pages/Rx-Transfer-Day-March-23-2012/154073404690861

  27. RealisticRPh says:

    Merck and Medco split up YEARS AGO! Where the hell have you been? But what’s hilarios is that Walgreens and Rite Aid have partnered with Medicare Part D providers and the chains are probited by law from recommending their plans to their customers.

  28. StudentPharmacist2013 says:

    This is what NACDS is doing! Check it out and participate!

    http://capwiz.com/nacds/issues/alert/?alertid=53248501&PROCESS=Take+Action

  29. Padenerik says:

    I had never heard the term “predatory audit” before, but that is exactly what it is. Our store just got hammered by Medi-Cal in California for doing a partial fill and monthly cycle fill for our patients in board-and-care facilities, even though we have been doing this for at least thirteen years. When we tried to explain to them that we are managing patient medications so the patients don’t run out of meds and go back into the hospital (about 90% of our patient population is schizophrenic or has other mood disorders), they basically said they don’t care and even questioned if we knew pharmacy law. We have been doing this for years and have been audited many times before, but all of a sudden they had a problem with it? Our profession will always suffer at the hands of third party payors until the day we all band together across the nation and say “No more. You can take your crappy reimbursements and predatory audits and shove them up your collective asses.”

    • Old Tyme Rx says:

      Padenerick, I think the independents would band together, maybe. There’s some predatory independents out there too, but forget the fucking chains. They’re whores and are loyal to no one and nothing. To thine bottom line be true.

  30. Old Tyme Rx says:

    Predatory audits? More like parasitic audits. The fucking 3rd parties are bad enough; now we have to deal with 4th party audits? The PBM’s hired guns like ACS waltz into YOUR store, scan YOUR files and you have to fucking pay YOUR people to help them screw YOU over. ACS just did an audit in my store. Targeted mostly group home patients on the big high dollar shit (like they always do.) Now, dig this~They’re trying to recoup money from scripts filled off a PMOF stating that we had the wrong doc’s name as the prescribing physician. Anybody that knows anything about group homes knows that only the “house physician” signs the PMOF, but all the specialists have to “initial” next to the drugs they had prescribed. The fucking kicker is that ACS won’t allow any “post-audit documentation,” even though the specialists wrote letters that they prescribed the fucking drugs. Wait, it gets deeper~the fuckers won’t allow our “manual signature logs post audit either.” HELLO ASSHOLES! YOU CAN”T GET A FUCKING ELECTRONIC SIGNATURE WHEN YOU DELIVER TO A GROUP HOME! NONE OF THIS SHIT WAS IN OUR CONTRACT WITH THE PBM. Hey, ACS, if you don’t know what a PMOF (PHYSICIAN MEDICATION AUDIT FORM) then don’t fucking audit it! What the hell am I thinking? They know goddamn right well what a PMOF is~just gives them another reason to fuck the independents over. Where the hell is our voice? How the hell is this happening? What the hell has happened to the profession? Sold down the river by a bunch of greedy bastards like APhA touting fucking cognitive services and MTM shit. APhA~BEND OVER, TUG ON YOUR EARS REAL HARD AND PULL YOUR HEADS OUT OF YOUR ASS! We need to be paid at least cost for the drugs we dispense, and we need to be paid a fee for services, and we don’t need fucking 4th party parasites making their living off our fucking blood sweat & tears. Does the Constitution and the law even fucking apply to pharmacy anymore? Oh yeah, excuse me; only when it can be used as a fucking bullet going through our temple…

  31. Railrph04 says:

    I have been in the pharmacy world for over 10 years including internship. This PBM and auditing has seemed to increase over the past few years. The Angry Pharmacist is correct about these issues. I remember that before Zithromax Z-Pack became generic it was a popular target by auditors because most doctors used the term “Use As Directed.”
    In reality that was fine to use because the package speeled out the “Take 2 today and 1 days 2-5″.
    Use as directed was acceptable when I started in the game but has become unacceptable by insurance companies more recently. It’s sad to think that our employer loses claims based on decimal errors or addition errors that happen so easily. I do not think any of us are human calculators, because if we were we would work in accounting.

  32. chris says:

    We had one audit, cannot remember by whom. The script was for a cream to be applied to the scalp bid. The auditers made us contact the MD and have them measure the circumference of the patients head in order to be reimburst! WTF!

  33. Phillip says:

    The APhA? Are you serious?? Those weenies are assholes who might have a pharmacy degree, but thought they were too good to remain behind the bench so they all make up these bullshit jobs that the members pay for!! That is their answer to getting out of the hell we deal with every day.

  34. Morgan says:

    pick out the letters AP at H etic Ass

  35. Maynard says:

    I worked in chain pharmacy for 20 years and i hear all the pain everyone is talking about. It was eckerd then cvs bought us out. In fact it was the same store i worked in, the entire time. I survived that long because i was a preceptor to a half dozen pharmacy schools and would gladly take a intern( or two) for free help. After cvs wanted me to start writing letters to my district manager on how on to improve my drive thru wait time and that i had to start dispensing oxy 30 , i decided i had enough. I hate the chains stores as well , i had worked independent and hospital since high school and college. I got out of cvs and its a MYTH that you make more money in chain pharmacy. I jumped out and now make 10 calls a day working for pbm doing mtm. pay and benefits went up 40k a year, My proudest moment now is that i have not dispensed a prescription in 2 and half years. If you guys dont get out now it will only get worse. I got out just as the immunization was starting in retail. I knew it wouldnt end. I feel you pain but cvs and wag can kiss my fat hairy pimply ass , get out now while you still have time.

  36. Ghent says:

    Thankfully, Kansas just passed a law banning any audit finding from adjusting reimbursements for any rx that meets state law as valid. Totally simple, passed by a huge margin. PBMs can still audit for true fraud, but we’re all protected from days supply issues, filing issues, clerical BS, etc…

    APhA ofc, doesn’t care. The only effective medical lobbies are the AMA and big pharma. Your local state chapter, however, might be much more useful.

  37. wiserph says:

    Important, you must be mentally challenged, Right?

  38. kEVIN says:

    Retail chain pharmacies are ponzi-esque, as their ongoing high-volume sale of tobacco, alcohol, and candy promotes and generates cancers and other medical disorders (e.g., obesity, diabetes, coronary artery disease), which further promotes and generates their selling of pharmaceuticals, many of which are of non-evidence-based and ineffective health care utility.

    • Morgan says:

      CVS did worse than that to me. Five years ago they fixed things so that I could never work again. I had a home foreclosure and forced retirement.

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