Should Counseling Be Billable?

Lawyers charge for talking with them in any sort of legal matter.

Physicians usually refer patients to come in before giving medical advice or any sort if they have not seen the patient recently or haven't addressed the issue in question before.

Most public speakers have an honorarium that they are given for showing up in support of a cause or set fee for their speech.

Nurse advice lines usually have a fee of some sort associated with them. If a problem is beyond their level of expertise they refer you to see a physician or nurse practitioner.

Think about it for a minute. Pharmacists provide essential information on how to take and best use a medication, as well as what to watch for and how to best control the problem being treated. Yet they have no real way of billing for this. Whether it takes one minute or an hour shouldn't there be a way to bill for this? This is a professional service, right? It does take my time away from others who need/desire it, that deserves some compensation right?

Now before anyone says I am being greedy, let me explain my reasoning for this. With ever declining reimbursements from insurance companies and PBM's (I'm looking at you Express Scripts!), a pharmacist has to dispense more and more medications to make a pharmacy financially stable. When the point is reached when a pharmacy can not be financially stable nobody wins, except those that created the scenario such as the PBM's. The reason nobody wins is because no patient safety and the quality of care is compromised to dispense a greater volume in less time. If the quality of care declines, so does the overall health of the nation and what is left is a vicious cycle that defeats the original intent. If patient safety declines then you could end up with more side effects, serious drug interactions and possible harm to patients.

Do you see the issue now?

I think it is despicable that reimbursements have gotten so bad (that's a post for another day) but the fact that pharmacists don't get paid for counseling is down right insulting! I know there are MTM services that we can get compensated for but all patients are not eligible for those. Every patient is eligible for consulting the pharmacist about there medication! I think it's actually mandated they must be at LEAST offered consultation in every state.

So if we must give our professional advice and opinions, why aren't we paid for it? The old argument that this "is our

duty" does not hold any water with me anymore seeing how much reimbursements for dispensing have fallen. How can I do "my duty" if it costs me time that forces me to lose money? I can't give professional advice for $0.40 as some insurance companies have proposed!

The solution could be very simple. Have a simple sheet to sign (or credit card like device) that the patient must sign saying the received consultation from the pharmacist. Include in it a simple time spent slot where the pharmacist and/or patient can fill in before they sign. You have complete documentation of how long the pharmacist spent and can be billed appopriately. I doon't think this will produce the positive results seen in full blown MTM programs however, I do think it would produce some significant difference from those who did not receive counseling. This would only apply to patients who were not eligible for MTM programs (i.e. a patient getting a new antibiotic, a methylprednisolone dose pack, etc.). In many cases, the proper use of these medications is vital to reduce rehospitalizations or follow ups, which in turn saves money while improving care.

This isn't a cure all solution BUT I do feel it is a step in the right direction to improve our healthcare.

-The Pharmer

Medcaid Fraud May Be Legal, As Long As You Get Their Permission

Medicaid fraud totaled around 12.9 million dollars in 2007 according to the U.S. Office of Department and Management. Medicare fraud was slightly less at $10.8 billion. Though this number may sounds shocking a fair amount of this may actually be due to the Medicaid and Medicare itself.

Near the close of business today I had a phone call come in from a patient's parent asking us to refill her son's necessary medication. I obliged and went about my regular duties while my technician filled prescriptions and did other small tasks. Withing 30 minutes of calling a woman showed up to pick up the prescription that was phoned in for a refill. I looked up the desired prescription and saw it was in troubleshoot due to an insurance problem. This is where it the government based programs ALWAYS get something wrong.

I opened the prescription on and saw that the problem was that Medicaid claimed the prescription was not properly billed to the child's correct primary insurance. To clarify his parent were divorced and his mother had custody BUT his father had insurance that still covered him and therefore must, by law, be billed previously before billing Medicaid. I double check with the patient and I had all of the correct information in the system. I fiddled with some rejection issues for billing 2 different insurances that I have picked up along the way. Still to no avail.

This means I have to face every pharmacists nightmare. The dreaded insurance call...

I got through amazingly quick (probably because who the hell is filling prescriptions on a Friday nigtht that isn't a pain med or possibly birth control). When I get through I am connected with Gino who was surprisingly pleasant throughout the call, unlike most people who I reach when calling Medicaid. I explain to him the problem, that the insurance is being billed correctly yet I can not get Medicaid to cover the rest. Gino gives me several more options that I did not previously try but all are futile.

Then it dawns on me.

I can go back and see how the prescription was billed previously. As I pull up how this prescription was previously billed I mention it aloud to Gino. Gino says, "Well that makes sense since that was the billing number that kept coming up on my screen." There is one major problem though. With the way I am billing this rather expensive prescription I am telling medicaid that I am actually billing a different insurance company than I am and I am also saying that I did not collect payment from the primary insurance. Basically I am telling Medicaid that I am not getting paid for this and they need to pay it in full.

This is Medicaid fraud by the book!

"Wow, you're right! My system is saying that's the only way we can cover this prescription but they are literally telling me to falsely file this claim!" I ask Gino to leave a detailed message for his supervisor and he gladly obliges. I can actually he him scuttering around papers and pens to start writing. I stated to him the only reason I am doing this is because 1. it's in the best interest of the patient and 2. he told me to. He agrees and says he will send the tapes on to his superiors as well. We exchange goodbyes and hang up.

The woman who was sent to pick up the child's prescription is staring at me now with her mouth agape. "Wait, so Medicaid told you to committ fraud? What the hell?" "My sentiments exactly," I replied. The woman then went on a tirade and starting laughing about how she couldn't believe it but was not about to complain since the child definitely needs the medication. I agreed with her but what was I to do since I was instructed by Medicaid?

As I go to ring the woman out I ask for the patient's date of birth. "I think it's... I don't know we all have too many kids," states the man she is with. Seriously, now Medicaid patients are admitting they have too many kids!?!?! I can't believe my ears! After hearing this I half expected some hell spawn to appear from behind the pharmacy counter but thankfully it did not. The woman gave me the correct info and was glad I could help and planned on contacting her social worker.

This child had several prescription, all costing in the hundreds of dollars, that had been filled for over 6 months like this! The only way this could have happened is if somebody called Medicaid to get the override and repeatedly billed it that way. I can only imagine how many times Medicaid has told other pharmacies to fraudulently bill them in similar situations. With that being said it is now wonder why so many government programs are in the red or that Medicaid fraud is around $12.9 million. When an average guy from a small town with a little common sense can prove how there is a major loophole in a system designed by "well educated" politicians who make careers out of setting up these programs it is no wonder our medical system is "broken". Maybe if somebody high up in the Medicaid or government reads this I can get a consulting job in which they will pay me millions once I prove I can save them billions.

Mr. President Obama, I think I just got you a few more bailouts so how about...