ATAP: Returned to Stock

Today we have another episode of Ask The Angry Pharmacist, where our very own TAP answers YOUR questions about life, pharmacy, drugs, and why that soma is too early to be filled!
Today we have a question by Adrienne:

Dear TAP,
Your rants are fantabulous. I agree with you and share your disgust. Thanks for exposing the real drug underworld. I have to deal with much of the much of the same BS; and then some. (Perhaps More about me another time.)
I have a billing and medical record question. I don’t have prescription coverage (self-employed so to speak).
Scenario: Someone with BC Fed brings in a Rx and the pharmacy says they have to “run it” to see if it’s covered.
Pharmacy fills the rx; it’s ready for pickup; but the patient doesn’t want to pay the copay or for whatever reason, they don’t pick up the script.
What happens to the meds? back on the shelf?
what does the insurance company/pbm pay the pharmacy?
what does ins co pay the pbm?
how does it go down according to the ins co/ pbm as though the patient received the meds?

Wow, fantabulous eh? Is that like Fantastic and Fabulous?
To answer your question, what you speak of is what we (in the “industry”) call “Returned to Stock” or RTS. RTS’d items are the bane of our existence and are a bigger money hole than a 19 year old mistress. Heres why:
1. We get the order for an Rx. We bill the insurance company and recieve cost+$1.50 (if you’re filling a MedImpact managed plan. Fuck you MedImpact!) for the work we do. We fill the prescription (using the insurance reimbursement thats above the drug cost to pay for the labor to fill your Rx. ie: the power bill, vial, label, my payroll, my tech’s payroll, computer costs, rent, etc)
2. You don’t pick up the Rx within a set period of time (usually 1 month, but varies between pharmacies). The Rx just sits there taking up space.
3. When the time is up, one of the clerks goes through every Rx waiting and picks yours out to be RTS’d. Since you did not pick it up, we have to REVERSE our billing to the insurance company, lose whatever money they gave us, and put the drug back. The PBM reimburses the insurance company (we hope) and the entire Rx filling process gets thrown into reverse. However knowing PBM’s, I doubt this happens.
4. This means that the pharmacy spent the labor to fill and unfill that Rx, but did not get paid. We lost all labor costs in filling that prescription (but we did not lose the actual drug cost since we can resell that drug that you didn’t pick up). Sure we can recoup the cost of the vial, but the label is lost, our labor in filling the Rx is lost, rent, power, etc. All lost. Plus we need to spend labor dollars to put that drug back in stock.
Obviously antibiotics are RTS’d sooner than other drugs, since why pick up an antibiotic 1 month after the ER called it in for you. Usually we do everything in our power to make sure you come in to pick up that Rx. Not only does it save us money, but it reinforces compliance and the feeling that “we care(tm)”. This involves paying someone to call you when you have medication sitting here looking for a home. We hope you would take the Rx after leaving the pharmacy, but once your signature goes into that log and you walk out that door, its all yours. No give-backs!
This is the reason why pharmacies are so reluctant to transfer medications that they have already filled for someone. If I call a pharmacy for a transfer, and the medication is filled and waiting for them at the other store, I will make them get it there this one time. Nothing pisses me off more than to fill 15 discharge medications from a hospital to have another pharmacy (*ahemWalgreensahem*) call and want me to back out (reverse from the insurance company) everything and send their way. I usually tell them to go fuck themselves (unless its a pharmacist I know, but those would never ask me to do something like that).
I hope that answers your question. If you at home have a question that you wish answered by a real-life angry pharmacist, please email questions@theangrypharmacist.com and I’ll do my best to answer what troubles you. Obviously more ripe/risky/personal questions get priority. Think of it like Love Line, only with someone a lot more angry (and funnier) than Adam.

Patients who kill your Patience

Retail pharmacy (or working with the public) demands one huge element that most students lack.  They don’t teach you this in school (although they should) nor do they even mention this anywhere in any textbook.  Its called patience, and as the day wears on my patience dwindles and dwindles.

However some of my patients act like patience sinks, quickly sapping me of my patience reserves and turning me into an angry, irritable asshole until the clock-out bell rings.  Since I haven’t done any sweeping stereotype posts in a while that piss people off, heres what you have been missing.

  • Old people.  Staring at you with those big empty eyes, you wonder what they received from of being alive for 75+ years.  They get confused /so/ fucking easily and make you explain things so many times you just wish they would go home and die.  The words “fixed income” somehow results in $1.05 being too expensive for their heart medicine as they smoke that $5 pack of camel filters outside of the store.  You honestly wish you could tell them “listen, you obviously aren’t mentally capable of taking care of your own medication, do you have anyone else that can help you?”.  Wait, Ms Smith is on the phone asking what “Once Daily” means again!
  • Mothers with misbehaving children.  If you had problems controlling one child, why on earth did you decide that having 2 or 3 more would be a good idea?  I used to warn the mothers when their children would scream out of the front door of the pharmacy while she’s looking at greeting cards or earrings.  Now I figure that once one gets hit by a car in the busy parking-lot she’ll learn to keep an eye on them.  Yeah, I’m a dick, but after warning them time after time to control their kids, you figure that maybe all of her intelligence and common sense was deposited out through her vagina.
  • Uppity poor people.  Entitlement, entitlement, entitlement.  Free, free, free.  To them, the world is fucking free and WHY IN THE FUCK are you not giving them trade name medication!  Don’t get me wrong; 99% are awesome people who really do appreciate what is given to them by the state and just take their Rx’s without complaint nor bitch.  The 1% however are begging for a one-way ticket to reality-check land.  From wanting trade-name medications to complaining about their almost non-existent copays, these folk ham it up in the poor department for a slice of the pity-pie.  I’m sorry, but I have stopped feeling sorry for you after you dropped $20 in earrings instead of that $1.00 copay for your kids antibiotics.  I wish these people would die in an Escalade fire.
  • Snobby rich people. I want TRADE NAME HCTZ.  They want trade name shit that hasn’t been trade name in 30 years!  They want trade name hydrocortisone 1% and trade name prednisone!  I wish I could give them generic and charge them AWP +10%.  Paying more for something must make it work better.  At least someone should get something out of all of the bitching.
  • Phillipino Home Health Nurses.  Along with being pushy as hell, can’t speak English, and barely know a fork from a spoon; when they finally get done barking out orders to me (like I’m sort of employee subservant dog of theirs) I have to use every ounce of patience to not give them both barrels on the phone.  I mean really, do you have to ask me why their blood pressure is up after you told me 2 seconds ago they have a FULL bottle of Norvasc sitting on their dresser?  Medication is only useful if you actually take it, so their potassium is not going to magically come down while that unopened bottle of Kayexelate I dispensed 2 days ago sits there untouched.  Last one called in orders for Humulin when the doctor specifically told her to call in Humalog,  Whoops.
  • PBMs (MedImpact, Argus, Blue Shield, Wellpoint).  Why did I go into this profession when I’m getting reimbursed less than my pizza boy makes in tips for 1 delivery?
  • Addicts. Lie lie lie, lie lie lie, lie lie lie.  MY DOCTOR SAID I CAN HAVE IT EARLY.  Listen, I don’t have the word “stupid” tattoo’d across my forehead, so after the 4th or 5th time you pull this “doctor said” bullshit (and I call the doctor to find out you lied to me 4 or 5 times), I’m going to stop calling the doctor and just outright tell you no.  Yeah, you’re in chronic pain; yeah, your fatsomyalgia is acting up again; but honestly, I can’t prescribe or dispense your dope early!  Its not my fault you burned every bridge with every ER and doctor in town who pegged your pills with “MUST LAST 30 DAYS”.  Crying to me isn’t going to work either.  Sure, I’ll transfer it to another pharmacy, only if you don’t come back.  This class of people really drains you as they slowly chip away your sanity and patience.  I mean after the 5th phone call to see if their pain pills were approved early you sorta just want to fill them so the’ll leave you the fuck alone.  They are worse than nagging children solely because their vote in the presidential election counts as much as yours.

And last, but finally not least:

  • My uppity readers.  These people somehow think this site is all about happiness or pharmacy-life.  Its not.  Its about the shit that pisses ME and every god damn pill-pushing pharmacist/tech out there off.  If you get offended, here is a novel idea.  DONT READ IT.  I’m tired of working 8 hours a day in an environment that has deemed it deeply offensive to speak your mind in the name of “Political Correctness” retarded bullshit.  I use this site to rant and bitch so I don’t go suck on the shotgun barrel of sanity.  So if you feel it necessary to tell me your life story about how you have chronic pain, and post some 40 page comment about how you think i’m an asshole thats fine, however know that I don’t really give a shit about you nor what your biased feelings are about pain management.  You’re going to justify that pill-seeking behavior is right and just dispite pages upon pages of pharmacists bitching about it.  So next time you feel ranty about how I’m a big meany pharmacist remember that you don’t work in a pharmacy (hell, you probably don’t work period!), I realistically don’t act at work the way I act here (duh), and there isn’t a retail pharmacist out there who wouldn’t stand behind this site and tell you “you’re a dumbass, TAP is right”. 

When bad PBM’s get even worse

Over the last 200+ entries, I have fought for truth, justice and AWP -5% + $6.50.  I’ve laid down the smack against doctors, other pharmacists, drug-reps, insurance companies, Liberty Medical (fuck you) and even myself.  Now someone else is on the angry chopping block.  This rant is a magical mix of useful information and gutter-talk.  My mother is probably so ashamed right now, however like most of our readers she forgets this is the ANGRY pharmacy and not www.MY-HAPPY-PHARMACIST-SON.com

Like a pimp who never loved you, these assholes of our profession both give us money, and screw our asses when we’re not looking.  Can’t live with them, cant work with them, but like a case of herpes wont ever be completely gone.

Yes, I’m talking about PBMs.  Pharmacy Benefit Managers.  The people who process your prescriptions and write out your checks every month.  WellPoint, Argus, Medco are all examples of PBM’s.  See on your insurance card at the Bin and PCN (Processor Control Number)? Thats so we can transmit to the correct PBM to get paid for your Vicodin and Soma.

You look confused (surprise surprise), let me use an example.

For those not in the profession (and 99% of the doctors out there), most insurance companies don’t administer their own pharmacy benefits.  Say for example we have a small Medicaid plan called “HealthPlan of AngryLand” (HPAL) that has hired a PBM called PillConcussion (PC) to process the pharmacy benefits.  When your local pharmacy processes that Rx for Soma, our computer systems contact PillConcussions servers (whom have a list of medications that HPAL has deemed “covered”) and right then we get a response if its covered and how much we are making.

PillConsussion pays the pharmacy for the Rx (say, $15).  HPAL pays PillConsussion what they paid the pharmacy ($15) + a handling fee (remember this!, more later).  So the flow of money goes:

State -> HPAL -> PC -> Pharmacy -> TAP -> Webhosting Bill/Booze/Hookers/Blow/Therapy.

Now, the big boys (BlueCross, Medco) process their own Rx’s, so the actual insurance company and the PBM are one in the same.  However smaller insurance companies cannot afford the infrastructure to process their own prescriptions so they hire a PBM (like PillConcussion) to mange their Pharmacy Benefits (hence the term Pharmacy Benefit Manager).  Now, this all may look fair and good, but what if PC goes crooked?

Example 1:
Brand new generic comes out.  Say its Paxil CR.  Now imagine that you have your head up your ass, and you processed the script for the trade name (because the patient has been on it for years) without switching it over to generic (which until this point you had no idea it was out).  Unless you look carefully at your reimbursement screen, the PBM will silently accept the transmission for BRAND NAME and reimburse you the price of the GENERIC (remember, you are transmitting the NDC of the TRADE name product).  No warning from their end, no “BRAND NAME NOT COVERED”, just a normal billing acceptance for about 95% under-cost.  That means that the pharmacy is getting the generic reimbursement ($4.00) when the PBM knows they are billing for the brand name ($200).  Your store just lost a shit-pot full of money because you blew past the reimbursement screen (although most pharmacy systems will blare warning lights at that point).  What makes this whole ass-raping even sweeter is that usually this shit happens when a new generic is released that the PBM’s know about long before you do.  Its pretty sad when the pharmacies find out that a new generic is available by the PBM’s gently patting your behind while softly telling you to lube up and bend over.

Example 2:
Say we take something random and stupid like Prilosec OTC and its generic Omeprazole OTC.  Now what if PillConsussion /only/ covers Prilosec OTC (the brand name), but reimburses the pharmacy the cost based upon Omeprazole OTC (the generic) and at the same time charges HealthPlan of AngryLand the cost of Prilosec OTC?   PC is billing HPAL the cost of the BRAND name, but reimbursing the pharmacy a cost based on the GENERIC.  Is this fraud? Would this be like the pharmacy billing trade name Cipro to the insurance company but dispensing the generic?  Its not as uncommon as you think, however most pharmacies are too busy/stupid to look at how little they are making and not speaking up.

Now in this example say that HPAL and the pharmacy talk and compare notes.  Like a guy who realized the girl he just nailed was 16, PillConcussion starts to do damage control.  They state that generic Omprazole OTC is not covered because the BRAND name is Omeprazole Magnesium and the GENERIC is just Omeprazole and they are not equivalent…

….Must ….Resist ….PBM ….Backward …Logic

Still doesn’t explain why they will not cover the generic but reimburse based upon the cost of the generic.. They then say that it was a computer error, and to BACK OUT AND RESUBMIT ALL CLAIMS FOR THE PAST X MONTHS.  Now here is what really confuses me.

If PillConcussion audited you, and realized that you were overcharging for a certain drug, would they have you BACK OUT and RESUBMIT all of the incorrectly billed claims? FUCK NO! They would just take ($difference x claims) out of your next check.  Now why can’t they do that with the errors that THEY made?  They know how much the price was off in the computer, and they know how many claims were processed, so why cant they just issue refunds to the Pharmacy (whom they were under-reimbursing) and to HPAL (whom they were overbilling).  Its bullshit that they make US do the work for something THEY fucked up on.  “I’m sorry that we fucked you, now get fucked even more with the $0.20/transmission charge you will get to BACK OUT and RESUBMIT to get an additional $0.50/rx”

Yeah, hear that sloshing noise, that’s coming from your backside.  Someone is getting the good end of this deal, and its not HPAL nor the pharmacy.  The processor is making MORE per Rx than the pharmacy, and all they have to do is just have a handful of servers setup to do processing.  The patients don’t even call them (nor know they exist).

This rant was started by an email I received about a PBM that is plaguing a good friend of mine.  I sent off a few emails to people in the area (I know a metric (not imperial) buttload of pharmacists everywhere, ah, fame) asking them about said PBM, and I received the same gripes/complaints from all of them.  This one however took the proverbial cake.

    I knew I was getting
fucked, but didn’t realize whose dick was in my ass.  All this time, I have
been blaming the insurance companies (who are not innocent by any means),
but it is the PBM that is really putting it to pharmacy and the health
plans.  These cock-smokers lower our MACs on a whim.  Hell, they
are lowering them before the fucking generic hits the
market.  Mean while you would think they would be lowering the
cost on those same meds to the health plan–no fucking way, the PBM pays us less
and doesn’t pass on the savings to the health plans.  Try to get
these same assholes to raise the MAC when
price goes up — good luck Charlie.  If you forget to dot an
i, they point that out without addressing the problem.  The cock-suckers
must be deaf and mute, because they can only communicate by email. 
If you work up the ladder at the PBM you begin to find
older pharmacist who at one time had their own pharmacies.  I have
to think they either couldn’t cut it without daddy’s money or tried to
fuck the public too much.  It is an IMPACT
we cannot afford to ignore.  You owners out there have a
choice–either stand up or lay down like a beaten dog.  Take the time to go
after these assholes now.

Now I’ve been sitting on this post for a long time, because this PBM decides to shoot themselves in the foot time after time (and I don’t want to make 100 posts about how shitty they are).  I just received an email from this same pharmacist saying that this PBM he is talking about (the one that has made an IMPACT on him) is doing an on-site audit at the end of August.  However they just audited him in March and found no significant errors (only stupid shit like a 1oz tube of cream being billed at 29gm instead of 28.95gm).  Now, I realize that sometimes we can be a bit slow, but since when do PBM’s audit you TWICE in 4 months unless you call them out on something huge and they want to get even.  What does a call to the auditor result in? “Oh, we’re sorry, this is a COMPUTER ERROR we will cancel the audit right now.”  Right, a “mistake” and a “computer error”.

So I’m just going to post this now, because I doubt that this PBM can shoot themselves in the foot any worse than they already do.