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?
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.
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.