Insurance fraud or something else? Weird prescription EOB.

[Pegasus]

So, several months ago, DH's doctor gave him some samples and electronically submitted a prescription.  DH had planned to see if the samples helped before picking up the script but the medicine arrived in the mail a few days later from a pharmacy across town (one we have never used).

 

I thought it was a little odd at the time but didn't give it much consideration.

 

Well, we just now got an EOB from the prescription portion of our health insurance that shows that the insurance paid almost $700 of the cost and that our cost would be over $1400.

 

My jaw dropped. I showed DH and he yelped.  I did a quick google search on pharmacy prices and it looks like this medicine routinely retails for around $200.  

 

Any ideas?  We have never gotten a balance due bill from the pharmacy so I'm picturing them gleefully collecting the $700 insurance money for a $200 prescription.

 

I did go onto our drug insurance website and did a search on their drug database and they have the drug listed as around $2100. That is very out of sync with the general pharmacy prices I can find online.

 

What would you do at this point? I really don't expect to be billed but I'm annoyed that our insurance way overpaid for a medication that DH may not have bothered to even have filled if it hadn't just been automatically mailed to us.

 

Also kind of concerned that the prescribing doctor may be involved in some sort of kick-back.  Otherwise, why would he have sent the script to a local pharmacy across town and why would they have mailed it instead of letting us pick it up? My own doctors always ask what pharmacy I want to use and it has never been mailed unless I specifically used the 90-day mail order program through the insurance plan.

[Lawana]

Yikes! I would be contacting the insurance company about the situation.

[Jean in Newcastle]

I agree with contacting the insurance company.

 

 

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[OrganicJen]

I would call the insurance company about it since they were billed for it from the pharmacy and they might be able to handle it.

[Seasider]

And call that pharmacy to be sure they don't have you set up on auto refill!!!

 

This seems to be something new I've also noticed - one of my physicians (eye doc) is on board with this direct-mail sort of Rx filling. I'd call the doctor's office to make it clear that they are not to automatically have prescriptions filled that way without your consent each and every time.

[displace]

So, several months ago, DH's doctor gave him some samples and electronically submitted a prescription. DH had planned to see if the samples helped before picking up the script but the medicine arrived in the mail a few days later from a pharmacy across town (one we have never used).

 

I thought it was a little odd at the time but didn't give it much consideration.

 

Well, we just now got an EOB from the prescription portion of our health insurance that shows that the insurance paid almost $700 of the cost and that our cost would be over $1400.

 

My jaw dropped. I showed DH and he yelped. I did a quick google search on pharmacy prices and it looks like this medicine routinely retails for around $200.

 

Any ideas? We have never gotten a balance due bill from the pharmacy so I'm picturing them gleefully collecting the $700 insurance money for a $200 prescription.

 

I did go onto our drug insurance website and did a search on their drug database and they have the drug listed as around $2100. That is very out of sync with the general pharmacy prices I can find online.

 

What would you do at this point? I really don't expect to be billed but I'm annoyed that our insurance way overpaid for a medication that DH may not have bothered to even have filled if it hadn't just been automatically mailed to us.

 

Also kind of concerned that the prescribing doctor may be involved in some sort of kick-back. Otherwise, why would he have sent the script to a local pharmacy across town and why would they have mailed it instead of letting us pick it up? My own doctors always ask what pharmacy I want to use and it has never been mailed unless I specifically used the 90-day mail order program through the insurance plan.

Likely the Dr. put in the wrong pharmacy, or a medical assistant did that. Usually, when pharmacies get a script, they fill it automatically. They do not ask the patients if they want it to be filled. A delivery pharmacy would probably just deliver it.

 

Call the pharmacy and refuse the script. It's surprising that the pharmacy was even able to fill it, because if you've never used them, they do not have your insurance information.

 

Regarding kickback, that is super illegal. It's unlikely a regular physician would risk their medical license and board certifications to be involved in something like that. Of course, there are unethical people in the profession as well. But, if there are no other red flags with the physician, and the story makes sense once you've called the offices and found out what happened, I wouldn't think that would be likely. Of course, if you find something very suspicious, you can always report it to your state medical board, and they will do an investigation.

Edited October 6, 2017 by displace

[TechWife]

That is really odd. If your husband kept the prescription, I don't know that there's anything you can do, though.  The doctor should have verified the pharmacy name first, then sent it to the pharmacy your husband indicated. When checking prices, be sure you are choosing the same strength and quantity. With the insurance paying that little, I would have to guess that either the pharmacy isn't in network or the medication is not on their formulary. It's also possible that your insurance just caps the cost they pay per prescription. In any case, I would call the insurance company to find out why they paid what they did, then take up the issue of the copay with the pharmacy if you receive a bill from them. In recent years, pharmacies have been really good about checking for coverage of medications and contacting patients with copay information before filling the prescription. With a copay that high, I am surprised that the pharmacy didn't call and ask for a credit card number to bill the copay before filling the prescription. 

[displace]

That is really odd. If your husband kept the prescription, I don't know that there's anything you can do, though. The doctor should have verified the pharmacy name first, then sent it to the pharmacy your husband indicated. When checking prices, be sure you are choosing the same strength and quantity. With the insurance paying that little, I would have to guess that either the pharmacy isn't in network or the medication is not on their formulary. It's also possible that your insurance just caps the cost they pay per prescription. In any case, I would call the insurance company to find out why they paid what they did, then take up the issue of the copay with the pharmacy if you receive a bill from them. In recent years, pharmacies have been really good about checking for coverage of medications and contacting patients with copay information before filling the prescription. With a copay that high, I am surprised that the pharmacy didn't call and ask for a credit card number to bill the copay before filling the prescription.

That's a good point, re:costs. My pharmacy informs me of costs either before filling or on pickup. I don't use delivery pharmacies but it's surprising they don't have a similar process. I can't imagine they'd be in business long. In the US, with the hundreds of different insurance plans, copays, formularies, etc, they should verify everything beforehand.

[Pegasus]

When checking prices, be sure you are choosing the same strength and quantity. 

 

:iagree: I was looking it up wrong.

 

I was typing the exact name of the medication but the internet information that was returning was the GENERIC.  DH received the brand name and, yes, it apparently retails for over $2100.  Yikes!  He never would have accepted receipt of it, knowing the cost. The doctor visit and prescription was in early March, seven months ago.

 

So, I guess now I'm surprised the pharmacy hasn't been billing us.  Still seems wrong that they can just mail it to you without you agreeing to the cost. I don't know how the pharmacy had our insurance information unless the doctor office shared it with them.  This was a local pharmacy across town so I'm sure we've never used them before.

 

Our insurance covers 30% of name brand drugs so the ratio of paid/owed seems about right.  :crying:

[SparklyUnicorn]

That is so odd.  They really should not automatically be sending anything.  Sometimes I get prescriptions and never pick them up.  They don't charge me or send them to me or even call me. 

[OrganicJen]

And call that pharmacy to be sure they don't have you set up on auto refill!!!

 

This seems to be something new I've also noticed - one of my physicians (eye doc) is on board with this direct-mail sort of Rx filling. I'd call the doctor's office to make it clear that they are not to automatically have prescriptions filled that way without your consent each and every time.

 

I hadn't heard of this, it's good to know thank you!

[Arcadia]

This seems to be something new I've also noticed - one of my physicians (eye doc) is on board with this direct-mail sort of Rx filling. I'd call the doctor's office to make it clear that they are not to automatically have prescriptions filled that way without your consent each and every time.

That seems liable to fraud. We always asked for the prescription as my nearest pharmacy is just a 10mins walk away down the road. We don’t have a pharmacy on file as I have three pharmacies within walking distance and just prefer to do it myself. Another thing to look out for.

[Tap]

My guess as a pharmacy tech.

 

Some prescriptions come with the person's insurance info in the script. Also, some companies computer systems are linked like Albertsons/Safeway /Vonns are all linked (same owner). So, if a patient fiiled a script at Safeway in Hawaii on vacation, an Albertsons in Washington has therir insurance info on file. A 3rd idea, is that one pharmacy bought tbe records of a pharmacy that closed. So, like the above example...a clinic pharmacy i. Hawaii may close, and Safeway bpugh3t tbe records. Now the Washington Albertsons has the records from a small clinic pharmacy in Hawaii. Lol

 

The reason you werent charged a copay...because they probably used a manufacturer coupon for your copay. Since it dropped the copay to zero, they mailed it to you.

 

Maybe not illegal, but definitely sketchy to mail a script without patient permission.

[Pegasus]

My guess as a pharmacy tech.

 

The reason you werent charged a copay...because they probably used a manufacturer coupon for your copay. Since it dropped the copay to zero, they mailed it to you.

 

Maybe not illegal, but definitely sketchy to mail a script without patient permission.

 

Ah, thank you. You are a genius.  I hadn't thought about the possibility of a manufacturer's coupon. We've had those for very expensive name brand medications in the past.  

 

The mystery is slowly resolving.  My thanks to everyone for their input.  That's the main reason I come to these forums.  Between everyone who is active posting here, we know everything.

 

:hurray:

[applethyme]

This happend with dh.  Apparently the drug rep had a deal with a pharmacy that if our doctors office would order xyz medication from this particular pharmacy, then the drug rep would supply coupons to make the drug free for this doctors patients.  When I finally go the whole story from the doctors office I was livid and made very clear that we will only use our local pharmacy and neither dh nor I want "new" drugs that are just reworking of older drugs with an extra ingredient or two.  

[Seasider]

That seems liable to fraud. We always asked for the prescription as my nearest pharmacy is just a 10mins walk away down the road. We don’t have a pharmacy on file as I have three pharmacies within walking distance and just prefer to do it myself. Another thing to look out for.

To be fair, when there's a specialty product involved, it may be necessary to get it from a specialty pharmacy (i.e., compounding).

 

As far as the auto renewal, I think that's just aggressive marketing. In my case, the product (second batch) showed up two weeks before my initial 30 day supply ran out. I felt that was an intentional shortening of the cycle. When a third batch showed up, I called and cancelled because I had specifically asked for only one refill. So they totally messed that up.

[Jean in Newcastle]

I might be wrong, but I don't think that a compounding pharmacy will have drugs that are listed in the drug database - at least not in their final form.  The whole point of having medicine compounded is because what is needed isn't available in a mass produced form either because it is experimental or because there is a reason why someone can't take the mass produced form due to a problem with the inactive ingredients etc.  I use compound pharmacies a lot and each one compounds things differently and thus has different prices as a result.  I have to call and ask questions every time I have a new compounded medication - including asking ahead of time what the price will be.  Depending on the answers, I may call multiple compound pharmacies to find the right one for the job.  (I've had to have some meds mailed to me from far away because local compound pharmacies don't deal with certain rarer preparations that the doctor feels are necessary.)

[Seasider]

I might be wrong, but I don't think that a compounding pharmacy will have drugs that are listed in the drug database - at least not in their final form. The whole point of having medicine compounded is because what is needed isn't available in a mass produced form either because it is experimental or because there is a reason why someone can't take the mass produced form due to a problem with the inactive ingredients etc. I use compound pharmacies a lot and each one compounds things differently and thus has different prices as a result. I have to call and ask questions every time I have a new compounded medication - including asking ahead of time what the price will be. Depending on the answers, I may call multiple compound pharmacies to find the right one for the job. (I've had to have some meds mailed to me from far away because local compound pharmacies don't deal with certain rarer preparations that the doctor feels are necessary.)

So compounded remedies was a bad example - mine is a specialty product for my eyes that I can use on a long term basis.

[AngieC]

I recently had a doctor's appointment and the doctor told me that two of the three meds prescribed would not be available at most pharmacies and he called them into a mail order pharmacy for me. There was no copay for one product due to a manufacturer coupon and there was a copay on the other. The third item was called into my local pharmacy.

 

Nothing about what you wrote sounds odd, except the fact that your husband didn't know, unless there was just a miscommunication.