This path of logic may only apply to Medicare Part D…. but may also apply to Medicaid and PBM’s.
When I had my own pharmacy we were the largest HME provider in two countries.. being so.. we had to understand the billing rules under Medicare Part B
When you are a Medicare Part B provider – you have the option of being a participating provider or not…
Being a participating provider.. you were obligated to provide any service that was covered under Medicare Part B when presented with a properly filled out form and the patient had a valid medical necessity. If you lost money on the service.. too bad.. you had agreed to be a participating provider.. you had no choice but to provide the service..
If you did not agree to be a participating provider.. you could elect to accept assignment on a particular service and were obligated on that particular product/service to accept the reimbursement that was a Medicare allowable… Or you could chose not to accept assignment… provide the service/product on a “cash basis”.. and the vendor was required to submit a bill for the service provided to Medicare and the patient would get reimbursed directly from Medicare. The only exception.. is that you could not take assignment on one product/service on a certain day and provide the same patient another product/service on that SAME DAY… and take assignment…
If you apply these general Medicare rules to Part D… a pharmacy signs a contract with an insurance company (Humana, Aetna, CVS/Caremark, Blue Cross, etc ) is the pharmacy now a participating provider under Medicare Part D?
If so, if a pharmacy turns down a valid/on time/medically necessary prescription are they in violation of their contract with the insurance company and thus making the insurance company in violation with the contract that they have with Medicare ?
I can hear it now… “In my professional discretion… I did not feel comfortable filling that particular Rx for that particular person “.. That may be true.. but how many times have you billed the insurance company for a Rx claim and they come back later.. during a audit ..and determined that you failed to properly document the claim and they “clawback” the monies paid for that claim.
So do Pharmacists now have to consider.. when turning down a controlled Rx.. if the patient files a complaint with the insurance companies and Medicare about denial of service.. that the pharmacy has promised by contract to provide.. and that complaint causes a audit.. it is determined that the Pharmacist’s professional discretion was WRONG or incorrect and the patient was denied a valid service. If it is determined that this happens routinely… will that put the pharmacy’s contract with the insurance company at risk?… will this put the insurance company’s contract with Medicare at risk.. especially if they don’t take corrective action ?
Will a board of Pharmacy view such a error/mistake.. like any other prescription error and could place the Pharmacist(s) at risk of being charged with unprofessional conduct , fined or license suspended?
Once again.. I am talking about pts with legally written Rxs, that are on time and for a valid medical necessity.. those Pharmacists that are doing their do diligence and documenting their reasons for declining… may have little to worry about.. others who are more focused on a reason to say no.. than a reasons to say yes… may end up having issues …
Filed under: General Problems
(The Difference between Dependence and Addiction of a controlled medication)
Let me clarify the difference between addiction and dependence of a opioid.
Physical dependence of a opioid is a result of your body becoming dependent on a opioid medication that gives you a better quality of life. Some chronic pain sufferers may take a opioid for years and live a somewhat normal life and never need a increase in milligram. Some people may need a small increase over a period of time ,if this gets to be a problem opioid rotation should take place so the dose does not get too high.Titration upward must be done correctly finding the pain suffers best available dose with little or no side effects. When the undertreatment of a chronic pain sufferer is done ,this is when a physician does not properly titrate the pain sufferer to an effective dose , the dose in normally to low and is a waste of time .
Properly treating people with chronic pain is paramount.
Addiction is entirely different than physical dependence. Addiction is an emotional dependence of a substance, where the addicted person will abuse a substance, regardless of the consequences, for a non-medical purpose. Addiction is when a person keeps taking the medication because it puts them in a better mood, or helps them deal with stress better, etc. Basically, a addicted person will start abusing the narcotic, for non-medical related reasons, but emotional ones. A addicted person will continue to abuse this opioid medication despite harm to themselves and others.
Ask any person with chronic painful diseases which they would prefer- narcotics or health. I know I would give anything to be able to go back to the job I loved and to be able to leave the bed without narcotics for pain. This is not a choice but necessity. There is no understanding or concern for the disabled only discrimination. I have no problems with pharmacies calling the doctor or doing background check.. My insurance pays the pharmacy and so do I. Why are the patients treated as criminals? Certainly pharmacies have the means to check out the differences. I do the drug screening and visits every 30 days for the last 8 years. My life until death releases the pain completely. Check away but please please don’t deny me the medication and make my suffering worse. I feel like I am speaking for others also with the same situations of being turned away. I appreciate the chance to speak honestly.
The recent lawsuit filed by former NFL players who were fed opioids like candy while they played then had to go ‘cold turkey’ and developed the addictive behaviors when they left the NFL hasn’t helped matters. IMHO.It was interesting from the news reports that team doctors and trainers were giving narcotics without prescriptions and without required documentation…..SO where are the medical licensing and trainer licensing boards on this one….Where’s the DEA raiding the NFL locker rooms on this or other professional sports? Also based on what I read in the articles, I think these players also have a good case for malpractice lawsuits if these team docs truly did not treat some of these injuries (ie Jim McMahon states he played with a broken vertebrae while the team doc knew but did not tell him or treat it, just plowed him with drugs and shots) within the guidelines of good medical practices.
I don’t know how true this is but I’m hearing this for the third time,,,,,
Oh an don’t forget that come the first of the year our president has more of his dirty laws coming out, one of the worst is that three different people from three different places can change the amount of pills a person get’s and the doctor has no power what so ever, the first is the pharmacy, the second is the insurance company, the third one is the government themselves.
A Pharmacist can INTERFERE with a pt getting their meds.. as the media starting to pay attention.. they are starting to back down from their “diety complex”.. Pharmacists are already getting threats from doc groups about “practicing medicine without a license” charges…The insurance company can only refuse to pay for certain meds.. they cannot otherwise interfere with a pt getting their meds.. The DEA is probably the only one that can truly cut a pt from their meds.. but they have to do it covertly.. they can’t come out overtly and due this.. but.. as I have stated.. they are forcing their registrants to violate the ADA.. at some point this will come back around and bite the DEA in the ass.. No matter how many years you look at the war on drugs being fought 45 yrs since BNDD or 100 yrs since The Harrison Narcotic Act.. it is too many years.. too many dollars.. too little progress… eventually Congress is going to cut the budget or pull the plug on the DEA.
Steve I truly appreciate your wiliness to fight for us who just cant because of our pain. I noticed JR did not answer your question if he would be willing to put in writing why he refused to fill a person script. Ignorance as well stating by her picture she looks like a addict. Really….Then to feel sorry the Pharmacy who were fined millions of dollars. Hmmmm the Pharmacist were filling pain medication without a valid prescription. The Pharmacy knew the prescribing doctor was running a pill mill but still filled those scripts. Pharmacy were making money hand over fist by the pill mills as the illegal pts were paying cash. So now the pill mills are closed and only valid PM doctors are prescribing meds for valid patients and we are being harassed. WTF is wrong with this picture? A little to late…..
Our Government is slowing making our wonderful country a socialism country. When the Government; ie DEA, Dept of Health, lots to list; dictate how a business operates and how a doctor practice medicine isnt the Government runny your business? In my opinion Obama care is a front for collecting data on us. As you all know if you filed your taxes this past year you were required to have health insurance. If you did not have insurance you had to apply. This is insane but yet those who want the government to take care of them are selling out. We are loosing all our rights our forefathers fought so hard for and created United States Constitution. My point is by treating patients as drug addicts without spending 24 hrs 7 days a week with us you are going against our basic Constitution rights.
Pharmacist need to stop being wimps and live up to your Pharmacist Creed. Stand up to DEA expressing you are capable of making a professional decision of filling a script or not. If you don’t then all you schooling was for nothing and pharmacist will be replacement by Government workers with no education. This issue is not just a problem for pain patients but for everyone except for the Government because they soon will be running your pharmacy.
I recently had a discussion with a long time friend whose sister is being treated for chronic pain due to degenerative disc disease. She was taking OxyContin 4 times a day with Oxycodone for breakthrough (sorry I forgot the strengths but they were pretty significant) She was able to function and work part time. But since ObummerCare when into effect, she was one of the millions whose insurance was cancelled because it wasn’t ‘good enough’ (so much for ‘If you like your plan you can keep your plan, PERIOD!) She was forced then to go one one one of the exchanges. Well this exchange has limited her Oxycodone to 1 tablet a day and her breakthrough oxycodone also to one a day, no prior authorizations, no appeals, no review of her medical history for medical necessity. So now she has had to quit work, she is trying to get on disability. She lives outside of my state. Her brother thinks she should try to move to Colorado…I told him she couldn’t afford the legal marijuana due to the huge taxes on it. I know he’s willing to do anything for her if it means buying something illegal to keep her pain free. He did when his mom was dying from cancer and was not getting pain relief. I hope not I guess my point is…Is this what we also have to look forward to when ObummerCare kicks in full swing if it’s this bad now?
It’s a shame that pharmacists cannot practice due judgement in the filling of prescriptions due to the fact that their actions are based upon many other extraneous factors. Besides the dea,state and Federal agencies now the chain
They work in, the availability of the drug, insurance requirements and the additional stress of Medicare and the ADA enter in.
As a pharmacist with over 35 years of experience and being educated in the era where pharmacy was practiced with the patient’s welfare first, I often wonder why we are always painted as the bad guy for many others (ie insurance companies, regulatory requirements, wholesalers and the pharmacies we work in).
The judgement of to fill or not to fill due to professional discretion is a power that pharmacists have been given by their professional education and state licensure.
Rodney Dangerfield said an analogy that represents pharmacy- To paraphrase “Pharmacists get no respect”
As a pharmacist I care about my profession and my patients however we have been placed in a difficult position of making a professional judgement- to dispense or not dispense. We now have consequences for both sides of the decision before even thinking of the impact of this decision on the patient.
Now with multiple disease conditions I too am faced with going to my personal pharmacy and hearing that they have no stock of my pain medication.
I cringe at those words because in my day I would never say I do not have that drug in stock instead I would tell the patient go to xxxx pharmacy and ask for joe the pharmacist for the drug. I guess we take one step ahead and two steps behind for addressing narcotic diversion and the war on drugs but I wonder how many people must suffer due to the over-regulation and watchdog review of our
Pain medications.
Georgia RPh according to the recent AMA statement Walgreens has you practicing medicine without a license and told doctors not to answer the questions. I’m not an attorney but I doubt a form like that would hold up in court on an ADA lawsuit.if you deny a legit pain patient his meds.
@william… apparently you did not read – or understand – the last paragraph of the post.. Those Pharmacists who are doing their due diligence and basically using facts to support the decisions that they claim is based on their professional discretion should have nothing to worry about.. Just like a audit from a PBM… if you have dotted all your “i’s” and crossed all your “t’s” the auditor walks away without any claims against the pharmacy. In case you haven’t noticed.. Heroin use/abuse/deaths are spiking.. those people that you are so concerned about getting opiates that are not medically necessary… all or nearly all.. are continuing to find some opiate or other substance to abuse.. If around 2% of the population is abusing some substance.. if volume of opiate doses drops more than 2%,, then “we” are denying legit pts their medically necessary meds. The DEA is using laws to fight the war on drugs and it is only proper for those people who are being abused by the system.. use the laws on the books that are there to help them to keep from being abused by the system. Maybe the day will come when the bureaucrats provide better, more user friendly tools to help us more accurately determine who are legit and who are bogus… I am unapologetic about trying to help those in the chronic pain community to level the playing field and get their necessary medications and those Pharmacist who do not do a competent job of making that happen.. because of fear of the DEA, personal phobias or biases.. then whatever comes down on their head.. is not my problem. They have a duty to patients.. they have taken a oath… you ought to read it – AGAIN… IMO… all too many pharmacists are failing both the patients that they are suppose to be serving and the oath they have supposedly pledged to honor.
There is a simple solution to end this bs. Do background CHECKS!!!so simple yet they dont do it and its ridiculous. If a person has a record especially drugs then there u go i wonder how many of these addicts are getting their prescriptions filled while the real patients get denied and treated like crap. I bet its alot. Especially from what ive seen.
Soooo if you’re doing like Walgreens does and checking things off a checklist and writing a comment at the bottom of the form saying anything else, you’re doing everything that’s necessary, right Steve?
GARPH.. it all boils down to what a investigator “thinks” is due diligence.. after the fact.. My understanding is that WAGS’ policy is not to fill any Rx for a patient if the doc/pt/pharmacy is not all in the same county.. My wife for example.. one specialist is in the next county.. and one specialist is not only in another county… but in ANOTHER STATE.. since we live 8 miles from the state border and there is no specialists like this one .. in the county we live in.. so if we went to WAGS – which we don’t anymore.. since they turned down a C-II for me.. after patronizing the store for 8 + yrs and first time I had a C-II filled.. I guess she would be just SOL. Luckily there is a Rite Aid two blocks away.. That I have known the PIC for some 30 years and they are more than happy to bill for some 15 K – 20 K/yr for us.
If anyone is paying an insurance company for Rx coverage and they have contracts with Pharmacies to fill/bill those Rxs and as a pt I cannot get my medically necessary/covered Rxs filled.. IMO – someone is violating their contract.. either the pharmacy with the insurance company or the insurance company with the pt. I am not sure how fondly that the insurance commissioner would view this.
My son is on Adderall and Zoloft and I have started to get the run around from WAGS on getting the Adderall filled. I usually use another pharmacy. However this past year he was at college out of town and had it filled at the college health center. (For security I would mail them the script to fill) I sometimes use the 24 hour WAGS for convenience when I know I’m not going to be able to pick up at my usual place during their usual hours. During his break, I dropped it off there…it was due on time, and got the run around on the due date 3 different times during the week he was home. The last one told me it wasn’t due until the date after he would be back at school. She said ‘Well he can get it filled there when he goes back” Sorry lady, you obviously don’t have a child with ADD, let alone know the chaos of the first few days of college after a break. That date is way past when he had it filled last. I asked for the script and ended up at my regular place and waited for it so he would have it when he went back to school. (I’m lucky he remembers his ADD and OCD meds, he sure did NOT remember his allergy shots). I’ve stopped using WAGS and I refuse to use CVS because I used to work there and they treated me like you know what before they fired me. BTW, I’ve also noticed the front store management working behind the pharmacy as if they are techs….but I seriously doubt they have tech licenses.
Pharmaciststeve,
I have posted some info on the subject of pharmacists fefusing to fill C2 prescriptions. I have been addressing this issue more from the legal point of view. There are court decisions that clearly state a pharmacist MUST fill every prescription. If you review the following website you will be suprised about this decision in the 9th Circuit court of appeals: dailykos.com/story/2009/07/10/752076/-Appeals-Fundie-Pharmacist-MUST-Fill-Prescipitions. There are many state and Federal regulations requiring a pharmacist to fill legitimate prescriptions as well as several rules that CMS, Agency for Health Care Administration, Medicaid, HHS, etc. I believe that these may establish precedent for other cases to provide strong ammunition for establishing firm rulings on this iisue. Please look at this and you may want to post about it at length. Thanks for all your help, Dennis Johnson
@paincare… you went to 9 different pharmacies and were refused service at all of them? maybe you’re giving off a vibe that makes people think you are not being forthright and honest. then again, if 9 different pharmacies all got the same impression perhaps its the right impression.
@steve… nice of you to stir the pot and try to mix in some fear into the doubt so that more drugs will make their way into the hands of abusers and diverters. way to go.
@all good pharmacists… trust your instincts. do not fill questionable rx’s. you know the good ones: fill them. you know the bad ones: NOT ONE SINGLE PILL !
Did u see her pic?wow these ahole pharmacists have been doing this discrimination bs for 2 years now. I have seen it w my own eyes people who DO totally LOOK like addicts getting oxycontin filled then i try to fill something HALF as strong and am told they dont have it lol this same thing happened to me last month and im really getting sick and tired of this i am in pain 24 7 and bad enough i am forced to work part time because disability doesnt pay enough to live on but to have to go through this every month too is complete bs. Can i tell them this month when they discriminate against me again that i will be filing a complaint with medicare or do i just go do it and contact medicare?
William,
Are you a little person with a little brain. By the size of that chair it seems apparent. How about I drive my car over your head and see how much it hurts.
pain… gee, what a nice person you are. you want to inflict pain on me so i become an addict like you? sweet. you should just stick to repeating what steve says. having original thoughts seems to be too much for you.
i had a broken arm. pain meds didn’t take away the pain. they just made me tired, impaired my judgement and fogged my memory. then the pain went away.
i had wisdom teeth extracted. pain meds didn’t take away the pain. they just made me tired, impaired my judgement and fogged my memory. then the pain went away.
i had abdominal surgery. pain meds didn’t take away the pain. they just made me tired, impaired my judgement and fogged my memory. then the pain went away.
that’s how narcotics produce addicts. you want the pain to go away but narcotics don’t work that way. the pain is still there but you don’t care about it because your brain chemistry is fucked up by the drugs. you keep chasing that pain-free feeling by ingesting more pills and higher doses but it doesn’t work. your doctor wants to help you so he prescribes more drugs for you even though he can’t find any medical reason for why you have so much pain.
but now its not the pain that hurts. its the withdrawl. you need the drugs to take away the heebie jeebies, not for the pain. now you have a life sentence.
my advice to you now… you need to find ONE pharmacy to fill your scripts. find one that will work with you and develop trust in you. stop hopping around to NINE different pharmacies. that has trouble written all over it. if the pharmacist doesn’t know you why should he care? take your meds as ordered. get your scripts filled on time. never early. and don’t be so bitter. life’s too short.
William ,
I do use one pharmacy to fill my medications, they where out of this particular medication that day, that’s why I had to look around to get that script filled.
William if the pain meds you take don’t take away your pain ,they just make you tired, impaired with fogged memory and no judgment just don’t take them. You might think you would have learned your lesson the second time you took them ,yet you continue to take them , its insane to keep repeating the same thing expecting different results.
And William you seem to be the one all worked up thinking you know me ,calling me a addict ,when indeed you don’t have a clue who I am.
Using foul language on a public blog is uncalled for. So please gather yourself and your feelings about other people and stay off those pain meds that impair your memory.
Seems they had a lasting effect on that little brain of yours because your judgment is way off .
Sorry if you think I’m being mean ,but you have to be careful how you speak to people. And William I don’t need your advice, but thank you anyhow, it takes a lot more than you to annoy me.
Have a nice weekend.
M.S.B.
i dont take drugs. i know its not wotth the risk. i’ve seen what happens to people who do. the pain will go away. my point is that if you never start you’ll never need to deal with addiction. the question to ask yourself is… are you treating pain or preventing withdrawl? of course, there is legitimate use. but after so many years on drugs you’re probably not in that category any more.
William,
You don’t understand people who have severe chronic pain that never goes away don’t get addicted, maybe dependent but where do you draw the line when the ongoing chronic pain is too great to live with day after day, hour after hour, minute after minute.
For the past 20 years I’ve had chronic pain in my cervical spine from a roll over car accident, when the roof collapsed it compressed my cervical spine and surgery is not a option for me. So who in their right mind would want to suffer every day all day. That’s my point. Yes it gets old going to the doctor and the pharmacy. It gets to a point to where it drives a person insane but luckily I don’t have depression. People see this in two different ways but if you had chronic pain for the past 20 years that drove you up the wall what would you do.
@William apparently you don’t seem to believe that there is both acute and chronic pain.. With Chronic pain pts.. there is a < 5% risk of becoming addicted. Of course, not treating chronic pain there is a risk of pt suffering from depression, anxiety, other substance abuse and suicide.
Oh William,
Shut up.
Continue to speak with ignorance about people in chronic pain and their response to medication, and others will know you for the fool you pretend to be.
Spend a lifetime disparaging souls who suffer with ignorant and hateful speech, and hubris will teach you the meaning of your words.
But learn to withhold judgement and let compassion flow through your body, and your fear will dissipate and your life may again be joyful.
We’re wasting our time trying to explain to William what chronic pain is compared to acute pain. Some people just don’t get it and William is one of them.
But that’s okay there’s others like William out there, clueless.
But we understand how some people don’t have the depth to think.
Sorry William but you need to think before you post and check your spelling.
Steve,
If this is the case the pharmacy where my doctor practices is in violation of their contract with the insurance company I signed up with and making the insurance company in violation with the contract that they have with Medicare. This is the first time I saw the cashier talk to the pharmacy owner and he looked at me and shook his head no. She said they where out of stock on this particular medication.
I said well then I want to leave this script with you till you get it in stock. She said she could not accept the script and hang on to it, is this a false statement.
I proceeded to go to 9 different pharmacies that didn’t have it in stock but found it at a hospital pharmacy I used a long time ago. Can I question the pharmacist on this and say your in violation of your contract with Medicare part D.
I’m not about to go do this pharmacy crawl again next month this time.
If I where to call the pharmacy I’ve used for the past 2 years do they have to tell me if they have it in stock or not, or can they just lie to get rid of me. Can I leave the script with them or is there this story true, they told me they cant hold on to a schedule 2 script because of the 21 day limit on the script.
For those of you who aren’t in the “know”, the pharmacies are being hit by the DEA in the same manner as the physicians are. They are setting regulations as to how much of what they dispense can be a schedule II drug and that covers all schedule II drugs, all of which are not pain medication such as Ritlan and other such drugs. This is coming from the top of the government. Before you start blaming the pharmacist for not having what you need on hand or being able to fill your prescription at all, please remember they aren’t doing this to create problems for you. They are trying to continue to stay in business at a time when it seems like everyone involved with treating chronic/intractable pain has their heads on the chopping block.
I have been informed that huge fines (to the tune of millions of dollars) are being levied on pharmacies which exceed this arbitrary percentage. The War on Drugs is a “war” on chronic/intractable pain patients, physicians, pharmacists and any other group that is a part of treating pain. I’ve actually had physicians tell me that they are treating according to their comfort level in writing the prescription and the patient’s quality of life doesn’t factor into that picture.
They are using the shock factor to get people on board with their party line of doing away with true pain management. They will hold up a bag representing the high dose a patient is on and the audience will gasp in horror. I suggested that they put the patient there who was taking those medications to show how they were alert, oriented, able to focus, and answer questions. I was informed that this scenario would never happen because that is not the message they want to send.
Let’s stop throwing rocks at those trying to help and go for the source of the problem. We have to take our issues to Washington D.C. as this is the head. This is where the orders are being given. They don’t care if patients die because at the end of the day they “look” good. They slash and burn, ruin lives and families but now they can point to statistics which sound good and the public doesn’t understand — they can say “we are winning the ‘war on drugs'”. After all it is much easier to go after the medical system than it is to wade back into the illegal drug “war” since physicians and pharmacists don’t shoot back.
‘The only thing necessary for the triumph of evil is for good men to do nothing.’
And how do we take our issues to Washington D.C. when most pain sufferers are on disability and can barely afford food and pay rent.
This sick way of saying their winning the War on Drugs is sad and insane. They will never win the war on drugs its impossible so they go after innocent doctors instead. Making us who suffer from chronic pain suffer even more. You all can thank our cool president for this.
What a pathetic excuse for a leader of the most powerful Nation in the world. Its sickening to see sick suffering people be stricken down by our own government.
JR.. are you willing to give patients a letter stating that your wholesalers is limiting your ability to order C-II to be able to fill their RXs? That way the patient can file complaints of ADA violation against the wholesalers.. Let the wholesaler deal with the DEA and ADA fines… What we have is one part of the DOJ (DEA) that is strong arming their registrants to violate ADA. I know that AG Holder is not big on enforcing our laws… but.. sometimes.. the best way to get attention is to hit someone in their pocket.. it seems to sure be working for the DEA right now. There are some 100 million chronic pain pts.. that are physically, mentally, financially exhausted .. just dealing with their disease issues. Pharmacists have never been known to stand up for themselves.. just look at thee average work environment of your “garden variety” chain pharmacist ! Are you willing to talk to a investigative reporter about how chronic pain pts and ADD/ADHD pts are being abused by the DEA ? I know at least one investigative reporter in your area.. I will be happy to try and get the ball rolling… This is your basic CLUSTER-FUCK… some pharmacists are damn lucky that my chronic pain wife is getting her medications without any hassle.. or I would be ripping some people a new one big enough to drive a semi thru.