Why Insurance Adjusters Hate Non-Network WC Pharmacies PDF

Why insurance adjusters hate us (a non-network WC- based pharmacy) + “dirty” tricks they’ll use to make sure an injured worker uses an in-network pharmacy  Insurance Adjusters/Insurance Carriers/TPA’s (used interchangeably) typically have one or more of the following six perceptions about...

Why insurance adjusters hate us (a non-network WC- based pharmacy) + “dirty” tricks they’ll use to make sure an injured worker uses an in-network pharmacy  Insurance Adjusters/Insurance Carriers/TPA’s (used interchangeably) typically have one or more of the following six perceptions about our service. Some of these perceptions are accurate. Others are not. We’ll cover these common perceptions. We’ll also contrast these perceptions with reality. We’ll also discuss some of the “dirty tricks” employed by the insurance carriers.  Section 1: Common Insurance Adjuster/Insurance Carrier(IC) perceptions about a pharmacy like EZ Scripts  In general, Insurance Adjusters (IA’s) GENERALLY think… 1) We’re too expensive 2) We take away some of the control an IA has over the claim 3) We cause more work for the IA 4) A pharmacy is a pharmacy- there’s no difference between WC pharmacies 5) All out-of-network pharmacies are “shady” 6) Mail-order medications take too long, and the PBM solves all medication issues (for everyone) Perception #1: We’re too expensive Perception Reality We DO cost more, in general. However, you get We cost too much money, and what you pay for, especially when dealing with obtaining medications via WC. they shouldn’t have to pay us We bill at the fee schedule, which we are legally more than the contracted rate entitled to do they have with whatever PBM We will never take the rates the PBM’s offer us now, they have a contract with at the because we would literally lose $$$ time We have additional costs that “chain” or “network” pharmacies do not have We overcharge and “a pharmacy What the insurance carriers pay the PBM’s is often is a pharmacy” higher than advertised, and it has ALWAYS been hidden from view We “take advantage” of the WC WC medications cost more because the system is system more complex. In other words, there’s good reason that fee schedules are higher for WC bills Perception #2: We take away some of the control an IA has over the claim Perception Reality When an injured worker (IW) uses us, they are The law is the law- and we stay well within the confines of it. In other words, until a law is passed (in any state) going “outside” of the carefully constructed that says that all worker’s comp meds MUST be system the IC’s have built authorized before a pharmacy can fill them, we will continue to fill w/o authorization from the IC Injured workers don’t “deserve” medications that aren’t authorized by the IC Some IA’s feel as if they have the wisdom and judgment of medical providers (that’s clearly false) IW’s aren’t hurt as bad as they claim, and they The vast majority of WC claims filed are “legit”. In fact, don’t always need the medications that are studies actually show that more fraud is committed by prescribed by the IW’s treating medical the IC’s and companies that procure WC insurance provider coverage Using a pharmacy like ours unfairly inflates the We DO inflate the value of a settlement (sorry Texas value of a claim, and costs the IC more $$$ in reps- no settlements in TX). This should be a main argument to any claimant attorney for why they should settlements refer EVERY WC client to us Perception #3: We cause more work for the IA Perception Reality By us being non-network, we This perception is 100% true generate a paper bill most of We cost the carriers an extra the time. This means that the $25-$30 per script- solely in IC/IA must spend extra time extra costs for processing a paper bill. and resources dealing with We are more than willing to join our bills (vs a network a pharmacy network (PBM), pharmacy) but we will only do it when the rate is fair and sustainable for us Perception #4: A pharmacy is a pharmacy- there’s no difference between WC pharmacies Perception Reality This perception is false. We know that WC is a very All pharmacies do is put pills in a bottle, and complex system, and it is more difficult for any medical which one is used for filling a claimant’s WC provider to navigate- and pharmacies are no different meds doesn’t or shouldn’t matter Most chain/network pharmacies aren’t equipped to deal with WC medications. We are specifically built to We provide the same service as any other accommodate WC medications for injured workers pharmacy Most chain/network pharmacies make most of their money selling retail items. Often, a customer filling meds lures them into the retail store, and the customers/injured workers also buy retail items. Because the rate these pharmacies receive for WC medications is so low, they're often afraid to fill without knowing that they will be paid for the medications. This is a major reason why IW’s have historically had many issues using these pharmacies for their WC medications. Retail pharmacies don’t have sales reps to help them navigate the WC system Perception #5: All out-of-network pharmacies are “shady” Perception Reality The industry has taken some hits, including the All out-of-network pharmacies are “shady”, largest and most well-known WC pharmacy and therefore anything “out of bounds” that That doesn’t mean that WE are unethical. Quite the IC/IA does when they’re involved is the opposite is true. The argument/thought justified process here is a logical fallacy called “guilt by Claimant-oriented medical association”. providers/attorneys are all unethical, and any Because we specialize in WC, and do it in many different states, we have a LOT of legal and group they associate with is unethical as regulatory “hoops” to jump through, when well compared to a local pharmacy. In other words, There’s really no reason that any injured we are hyper-aware of what we are required to do, and we do it worker should use a pharmacy like ours, so Our focus is on the injured worker- ALWAYS! We we MUST be doing some out-of-bounds do the right thing for the injured worker, because things to gain their business (this is a they’re ultimately the person that matters in WC common misconception) Perception #6: Mail-order medications take too long, and the PBM solves all medication issues (for everyone) Perception Reality In reality, 50% of the time a WC medication isn’t authorized when Because we’re a “mail-order” pharmacy, using submitted for payment. Even when they are authorized immediately, that doesn't mean that the IW will always get them the same day us will take too long In short, getting their meds the following day is often the BEST an IW We’re more like a Medco than a Walgreen’s, can do when they use a local/chain pharmacy. Their best is our default CVS or Rite-Aid We’re built specifically for processing WC claims- we are experts in The PBM they contracted with has promised this complex field PBM’s CAUSE a lot of issues for injured workers (backdoor that they will ensure that prescription issues formularies, unnecessary authorizations, $$$ thresholds built into their are a thing of the past algorithms A PBM “first-fill” program DOES NOT guarantee a fill. Claims that The PBM they use has a “first-fill "program, haven’t been accepted by the carrier are excluded. Also, the PBM card sent to the IW can be revoked or not honored at any time which guarantees that a patient will receive We use fedex for delivery, and that’s because of their capabilities and their first medications, no questions asked safety record. We do not use the USPS, because they can’t always guarantee delivery by a certain time + they are less secure than Fedex Using the “mail” for delivering medications is (or UPS, for that matter) unsafe, unethical or even illegal (I’ve had the There are no federal or state regulations that prohibit us being used as an out-of-state pharmacy. Whatever requirements we need in any latter accusation thrown at me before) specific state are fulfilled. In short, using us is allowed  Section 2: “Dirty Tricks” IA’s will use to scare the claimant away from using us “Dirty Tricks” by IC’s/IA’s when trying to steer a WC IW away from using us Threatening Injured Workers (verbally) Threatening Medical providers that refer to us (loss of business) Strongly worded PBM cards/letters to injured workers Threatening to not pay if we (non-network pharmacy) are used Denying our bills, then paying for the same meds at a local/chain pharmacy Quarterly PBM reports tend to amplify bad carrier behavior Slander/defamation (example in San Antonio)  The End Questions/Comments?