Can’t fight a battle with just one bullet !











Some how this imagine seemed appropriate in this “war on patients” being waged by the DEA and the “fall guy” is that RPH behind the counter with that “deity complex” .. routinely exercising their “professional discretion” when in the world of chronic pain management.. they are mostly clueless … it just seems appropriate 🙂

Here is a first draft letter   letterinsurance  – consider it a template/guideline for patients to use. Feel free to modify to suit your own particular situation.. I would suggest that it be sent as a certified letter to the legal dept of your insurance company.

I have already posted about ADA violations, unprofessional conduct, pt abuse, denial of service, wholesaler’s rationing, pt torture

But beside the DEA being a cause of most/all of the problems.. there is you friendly monolith health insurance company..

The insurance company is gladly collecting premiums from pts.. that constitutes a CONTRACT between the pt and the insurance company .. you give them money and they in turn agree to pay for certain products/services.. in part or totally.

The insurance company has contracted with a “pharmacy network”  either  directly or indirectly via PBM ( Prescription Benefit Manager) like Express Scripts, Caremark and others to fulfill that portion of the contract with providing/billing  the pt’s needed/medically necessary/covered medications.

I am hearing from various pts across the country that some of these contracted pharmacies are refusing to fill certain Rxs, refusing to bill for – insisting the pt pay cash for what are otherwise covered medications.. I am not an  attorney.. but.. that would seem to be a violation by the Pharmacy of their contract with the insurance company.

The above letter is intended to inform the pt’s insurance company that the pharmacy is seemingly in violation of their contract with the insurance company.. giving the company time to get the pharmacy to conform with the terms of the contract or cancel the contract.

If after receiving such a letter and the insurance company does nothing to intervene on the pt’s behalf with the pharmacy.. then it may be that the insurance company is happy with getting premiums paid and not seeing that their pharmacy network is providing products/services… the insurance just makes more money?

Again I am not an attorney… but.. if a entity takes money in exchange for providing a product/service .. and doesn’t… isn’t that FRAUD ?

If Medicare/Medicaid  is involved then the insurance company may be in violation of the contract that they have with CMS… again isn’t that FRAUD ?

I know that I  have yet to see anyone from a large corporation go to jail over Medicare/Medicaid fraud and abuse.. BUT.. there has been some major fines imposed.. just recently OMNICARE paid 124 MILLION for such Medicare/Medicaid fraud..and their former RPH employee got a 17 million share of the fine..  because he became a whistle blower and turned them in..

Don’t forget … somewhere in this mix is the state insurance commissioner.. I suspect that they would like to be made aware of insurance FRAUD in their state.. BUT.. that is just a guess on my part. AND  don’t forget the media.. and send you Fed/State representatives copies of all of this “going-ons”


7 Responses

  1. @Claire…Just curious..when you called the insurance…how certain are you that you were speaking to someone in the US? So many of these places have outsourced their customer call centers to Philippines, India, etc and these people usually speak almost clean English and give you an American first name. When I worked for CVS, I had their health insurance and had an issue. I called the member number. Turned out I was talking to someone in Manila, Philippines, and NOT the USA! I’m fairly good at picking up accents, even slight ones, so I asked where they were. Those outsource centers are just looking at a screen, they don’t have any details. That’s probably why you got such a run around. Fast forward to now..a little off topic..I’m dealing with GM on a recall…yes, they outsource. I had to demand to be routed back to a US call center..told the guy I understand you’re doing your job, but I can’t believe a US car company has NO call centers in Detroit..sheesh

  2. Steve, my fiancé has Medicare part D. Last summer when we had so much trouble finding a pharmacy to fill his prescriptions, his Medicare part D encouraged me to send them there to be filled and shipped back. They use CVS Caremark. So they had his prescriptions (plus a 19.95$ money order to ship quicker) for about 6 weeks then sent it back to him after I had called every few days to check on it and was told everything was fine. They said they could never get in touch with the Dr. The Dr. Office has a record of speaking with them. They also lost his money order. After calling very upset because he had no meds, they told me to send the scrip back to them and they would fill it ASAP. Then I get the run around again. It was supposed to ship one afternoon. The next day they said they can’t reach the Dr. I went to the Dr. Office and sat there while the Dr. Talked to them. The next day they said they sent the scrip back yet again because they could not reach the Dr. When I told them they were out and out lying, that I was there when they talked to the Dr., they THEN told me that they “did not like his Dr., that she was on a do not fill list for CVS. Needless to say I was infuriated. They lied and played games for TEN WEEKS while he suffered. Silverscript, his Medicare part D said there is nothing they can do about it. What should I do in a case like this and have you ever heard of such a thing?

    • CVS/Caremark and Silver Scripts are ONE AND THE SAME COMPANY !
      Silver Scripts is the insurance, Caremark is the PBM and CVS is the pharmacy.. pretty neat little controlling package.
      quote from their website:

      Who is SilverScript?

      SilverScript stand-alone Medicare Part D prescription drug plans are sponsored by SilverScript® Insurance Company, a CVS Caremark company. SilverScript contracts with Medicare to provide simple and complete prescription drug coverage to members in all 50 states and the District of Columbia1.
      Medicare Part D Coverage Designed for Life

      While SilverScript continuously looks for ways to improve efficiencies and lower plan costs, we strive to ensure member prescriptions are filled accurately, claims are processed efficiently and copays are exactly as described by the plan. You can feel confident about their prescription drug coverage leaving them to focus on living life and staying healthy.
      From you description.. it sure sounds like they did not live up to “WHO IS SILVER SCRIPT ?”
      It would seem that your next step is to file a complaint with the state insurance commissioner and CMS. CVS/Caremark is always being fined for something from DEA to SEC… there is a pending big whistle blower, ADA, EEOC lawsuit against CVS by a former RPH/PIC in PA. Just do a web search of “CVS/CAREMARK fines” and see all the results. Many pharmacists question if the company has any ethics.. and apparently – from you have stated – they are not above lying to pts over what is going on with their Rxs . If you have any problems in filing complaints.. feel free to contact me.. will be glad to help in what I can…

  3. So we should swnd this letter to medicare?even if it is just being denied and lied to by the pharmacists? Or is it only for the ones asking for cash?

    • If you are referring to Medicare Part D.. that drug coverage is being provided by some insurance company (Humana, United, Silver Scripts..etc).. there could be a PBM (Prescription Benefits Manager) – (Express scripts, Caremark etc..etc..) contracted with the insurance company to provide claims adjudication of the claims from the Pharmacy. IMO.. it is the responsibility of the insurance company to make sure that pts get their meds and billed to the insurance company by a pharmacy. This letter is designed to be sent to the insurance company to give them the chance to get their pharmacy network to adhere to their contract… If the insurance company elects to ignore your concerns (blows you off) .. then the insurance company may be in contractual violation with Medicare.. which is under CMS ( Center for Medicare/Medicaid Services). IMO.. you can send it directly to CMS.. but.. I think that a pt will get better results going up the line of contracts and give each entity the right to correct the issue.. and then you can go to CMS and tell them that you tried.. but no one would listen to you or take action.. IMO.. that would demonstrate a blatant disregard for the terms of the contracts. Personally, I would file a complaint with the state insurance commissioner at the same time of filing a complaint with CMS.

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