Insurance Adjuster Views on Non-Network Pharmacies

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Questions and Answers

What is EZ Script's stance on joining a pharmacy network (PBM)?

  • EZ Scripts is open to joining a PBM if it offers fair and sustainable rates. (correct)
  • The author is willing to join a PBM only if it provides a wider variety of retail items.
  • The author believes that joining a PBM will lead to lower rates for injured workers.
  • The author is against joining a PBM under any circumstances.

What does the author compare pharmacies filling worker's compensation (WC) medications to?

  • Putting pills in a bottle.
  • Navigating a maze. (correct)
  • Filling prescriptions for a regular patient.
  • Selling retail items in a store.
  • Providing a service that is not always profitable.

Why do chain/network pharmacies often hesitate to fill WC prescriptions?

  • They prioritize the needs of retail customers over WC patients.
  • They are not equipped to handle the specific requirements of WC medications. (correct)
  • They lack the necessary technology to fill WC prescriptions.
  • They fear that WC patients will not pay for their medications.

Why are fee schedules higher for worker's compensation (WC) prescriptions?

<p>WC bills are higher, due to the complexity of accepting WC claims (D)</p> Signup and view all the answers

How does the author address the perception that injured workers (IWs) are going 'outside' of the system by using independent pharmacies?

<p>The author refutes the perception by explaining that legal regulations allow IWs to use whichever pharmacy they choose. (A)</p> Signup and view all the answers

Why are out-of-network pharmacies, like EZ Scripts, often perceived as more expensive compared to in-network pharmacies?

<p>They are not bound by contracts with insurance carriers and can charge higher prices. (B)</p> Signup and view all the answers

According to the provided content, what is a key reason why the author believes that EZ Scripts does not overcharge?

<p>EZ Scripts bills at the fee schedule established for workers' compensation medications. (C)</p> Signup and view all the answers

In the context of the provided content, why might workers' compensation medications cost more than regular prescriptions?

<p>The system for processing workers' compensation medications is complex and adds to the cost. (B)</p> Signup and view all the answers

According to the provided text, why might an injured worker prefer to use a specialized work comp pharmacy instead of a local pharmacy?

<p>Specialized work comp pharmacies have more experience handling the paperwork and regulations for work comp medications. (C)</p> Signup and view all the answers

How do non-network pharmacies, like EZ Scripts, justify their higher costs?

<p>They assume risks on behalf of the patient, they provide superior customer service and personalized care to their patients. (A)</p> Signup and view all the answers

Why might insurance adjusters be concerned about an injured worker using an out-of-network pharmacy?

<p>They might lose control over the claim and the medication selection process. (A)</p> Signup and view all the answers

What is a common misconception about the role of a Pharmacy Benefit Manager (PBM) in work comp medication scenarios?

<p>PBMs guarantee timely and efficient delivery of all medications needed by injured workers. (D)</p> Signup and view all the answers

Based on the provided information, which of the following statements about work comp medication authorization is accurate?

<p>Obtaining authorization for work comp medications can sometimes be difficult, even when the medication is medically necessary. (C)</p> Signup and view all the answers

Flashcards

Pharmacy Benefit Managers (PBM)

Organizations that manage prescription drug benefits on behalf of health insurers.

Workers' Compensation (WC) pharmacies

Pharmacies specifically designed to cater to injured workers' medication needs.

Chain/network pharmacies

Large pharmacy chains that may lack specialization in WC medications.

Richness of WC medication services

The degree of specialized care and attention given to WC medications by certain pharmacies.

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Financial sustainability for pharmacies

The need for pharmacies to receive fair compensation for WC medications they provide.

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Retail items sales in pharmacies

Purchases made in pharmacies that drive their revenue beyond just medications.

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Challenges of utilizing chain pharmacies for WC medications

Difficulties injured workers face when filling WC prescriptions at non-specialized pharmacies.

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Injured workers' access to medications

The ability of workers to obtain their prescribed medications for workplace injuries.

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Insurance Adjusters' Perceptions

Common beliefs insurance adjusters have about pharmacies like EZ Scripts.

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Perception #1: Cost

Insurance adjusters believe out-of-network pharmacies are too expensive.

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Reality of Costs

Out-of-network pharmacies may cost more but provide better services and care.

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Control Over Claims

Adjusters feel out-of-network pharmacies take away their control in claims processing.

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Workload Increase

Adjusters believe out-of-network pharmacies create more work for them.

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Pharmacy Differences

Not all pharmacies are the same; services vary significantly, especially for workers' compensation.

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Stigma of Out-of-Network Pharmacies

Adjusters view out-of-network pharmacies as potentially 'shady' or unreliable.

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Mail-order Medications

There is a belief that mail-order medications take too long to deliver.

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Role of PBMs

Pharmacy Benefit Managers (PBMs) are assumed to solve all medication issues, but this may not be true.

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Hidden Costs in WC System

Insurance carriers often pay more for medications than advertised, leading to obscured costs.

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Misconception of Control

Some believe pharmacies take away control from insurance adjusters (IA) over claims.

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Legitimacy of WC Claims

The majority of workers' compensation claims are legitimate; more fraud occurs with insurance companies.

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Cost Implications of Non-Network Pharmacies

Using non-network pharmacies generates extra billing costs for insurance carriers, costing more per script.

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Pharmacy Authorization

Currently, workers' comp medications can be filled without prior authorization from insurance companies.

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Inflated Claims Perception

Some believe that using specialized pharmacies inflates the settlement value for workers' comp claims.

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Guilt by association

A logical fallacy where one blames a group for the actions of some members.

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Out-of-network pharmacies

Pharmacies not contracted with an insurance provider, often misunderstood as unethical.

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Specialization in WC

The focused expertise of pharmacies on workers' compensation medications.

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Medco vs Walgreens

Comparison of a mail-order pharmacy like Medco to a local chain like Walgreens.

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Medication authorization

The process of getting prior approval from the insurer for medications.

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Perception of mail-order speed

The misconception that mail-order pharmacies are slower than local pharmacies.

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Claimant-oriented medical focus

Prioritizing the injured worker's needs in medical decisions and services.

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Legal and regulatory compliance

Following laws and regulations specific to workers' compensation in pharmacy services.

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Insurance company involvement

The role insurance companies play in the authorization and payment of medications.

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WC medication delays

The potential lag in receiving prescribed medications after authorization.

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Study Notes

Insurance Adjuster/Carrier Perceptions of Non-Network Pharmacies

  • Insurance adjusters (IAs), insurance carriers, and TPAs often perceive non-network pharmacies negatively.
  • Some perceptions are accurate, while others are not.
  • Common perceptions include:
    • Non-network pharmacies are too expensive.
    • They decrease the IA's control over the claim.
    • They add extra work for the IA.
    • There's no difference between WC (Workers' Compensation) pharmacies and other pharmacies.
    • All non-network pharmacies are "shady."
    • Mail-order medications take too long, and the PBM solves all medication issues.

Reality of Non-Network Pharmacy Perceptions

  • Perception #1: We're too Expensive:
    • Non-network pharmacies generally cost more.
    • Costs are often higher due to additional expenses (e.g., operations, staffing).
    • Insurance carriers are often paying less upfront than advertised.
    • Worker's Compensation (WC) medication costs are higher because of increased complexity.
  • Perception #2: We take away control:
    • The law mandates filling medication prescriptions outside the control process.
    • Claims that aren't supported by medical evidence are unlikely to be approved.
    • Many WC claims are legitimate.
  • Perception #3: We cause more work:
    • Non-network pharmacies often process claims differently.
    • Extra work for IAs is a fact, but the overall system complexity often causes the issue.
    • Non-network pharmacies charge a small fee for processing paperwork.
  • Perception #4: Pharmacy is a Pharmacy:
    • Worker's Compensation pharmacies are vastly different from traditional pharmacies.
    • They possess unique capabilities needed for WC claims.
  • Perception #5: All non-network pharmacies are Shady:
    • This is a false and unsubstantiated perception.
    • Many non-network pharmacies are legitimate and follow all rules.
  • Perception #6: Mail order is too slow, and PBM solves all issues:
    • Many legitimate medication claims are initially delayed.
    • PBMs (Pharmacy Benefit Managers) don't resolve all issues.
    • Medication delivery can take time, though it is not always slow.

"Dirty Tricks" of IAs

  • IAs may use tactics to steer injured workers away from non-network pharmacies.
  • Such tactics can include:
    • Threatening injured workers.
    • Threatening medical providers.
    • Using strongly worded letters to injured workers.
    • Denying a bill, then paying for the same medication at a local chain.
    • Quarterly reports to amplify bad behavior.
    • Slander and defamation.

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Why Insurance Adjusters Hate Non-Network WC Pharmacies PDF

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