Getting Reimbursed for Services Rendered: It’s no Magic Trick

Elmo was an elderly patient with heart disease whom I enjoyed taking care of at the pharmacy. He was a brilliant chemist who had retired from the paper mill. He was so bright that many people saw him as a bit eccentric. We frequently discussed our mutual hobby: being amateur magicians. Elmo frequently conducted his own magic tricks, and often shared his ideas with me.

Elmo gave me an important piece of advice one day; “Whenever a group at church or a civic organization asks you to do a show or benefit, always charge them.” I winced! He said “always give them a price, and when you are done, you can sign the check and give it back to them.”

I was puzzled. Then Elmo explained “You see Pete, if you offer to do it for free it has no value to them”

Last week, a young and charming young lady named “Cathy” came into the pharmacy. She wanted to transfer her Minastrin 24 (norethindrone acetate and ethinyl estradiol/ferrous fumarate) prescription from a “big box” drug store. She was concerned about her copay, which was previously $52.40. I offered to call her OB/GYN so see if we could arrange to get one of the numerous available generic oral contraceptives. Within a couple of hours, her doctor returned my call and changed the prescription to norethindrone/EE 1/20. My tech processed the new prescription and it was approved, with a $0.00 copay. Cathy was most pleased with our pharmacy and left a very happy patient indeed. Saving $52.40 per month should make anyone happy!

When I explored this change, I realized that a pack of Minastrin has a whole acquisition cost (WAC) of $155. The generic norethindrone/EE was reimbursed to us as $17.77 (with no copay). I not only saved “Cathy” $52.40, but I saved the insurance company over $83.00! Cathy thanked me profusely, but I am anxiously waiting for the insurance company to call me with their gratitude. Maybe they will buy my staff lunch, or better yet send me a check!

I have a binder full of interventions I’ve done over the past three years, and marvel at how much money I, like you, have saved our patients. When I get our local dermatologist to change from Clobetasol cream (WAC=367.00/60 gm) to betamethasone augmented (WAC=$55.40/50 gm), I focus on the patient-savings and seldom think about the hundreds saved by the insurance company. The insurance companies have all these data, but they like so many other entities don’t make any effort to “share the wealth” that we pharmacists save them every day!

There is a huge effort to get pharmacists “provider status,” which is long overdue. While we are at it, let’s develop those drug utilization override (DUR) codes to include cost saving reimbursements to pharmacists for what we do day-in-and-day-out. Let’s also have these codes to use when we refuse to fill a prescription. Right now, there is no financial incentive for a pharmacist to decline to fill a prescription. With the opioid and benzo crisis in America, it makes good sense that we get a professional fee when we provide a service to help stem the opioid crisis. The PBM’s have the data as well as the money. Pharmacists use their expertise to help their patients, as well as the insurance companies, and we continue to go unreimbursed.

We do it for free. Like Elmo the magician said “because you do it for free, it has no value to them.” Let’s get that fixed too!