I appreciate your response and in no way to I consider it a personal bash. I rather read your response and know how my words are being interpreted so that maybe I can explain better. I find the hardest thing about the written word particularly between strangers is that we are missing the human element. In spoken word you can say the same thing and give it different intent or meaning by changing the inflection for your voice or your facial expressions or gestures. In the written word you don’t have those elements so the way it is read may not be the “voice” in which it was written. Knowing this that is why I preface my post with “Don’t shoot the messenger.”
That being said, my post was not simply my opinion though, in hindsight, I didn’t give you any foundation to understand where I was coming from.
My opinion is there should be nothing wrong with it and it is wrong for insurance companies to be cutting patients so close. You have no idea how much this irritates me (and that whole we rather cut you short vs. give you a few days over 30 days, OR charging you two copays because the prescription lasts you 40 days vs. 30 days- That’s a Medicare favorite). Every time we talk about disaster preparedness, we always hear how we should have ample supply of our medications on hand. How do they expect us to do this when they cut us so close?
My actual opinion on whether it constitutes fraud is actually very conflicted. My personal beliefs is no, not for the reason given. However, I am a paralegal by training and that part of me is at war with my personal beliefs. Years ago I had this exact matter come up when a pharmacy questioned a prescription’s directions because the person wasn’t filling their prescription in time with how the directions were written. (Personally, I get it and the doctor didn’t care if the person was giving themselves extra cushion. The doctor wants people to have extra cushion.) That was the first time I was told it was insurance fraud. Having the legal background, I wanted to know if that was accurate and, more importantly, how could we do what we needed to do so that it wasn’t fraud but the patients could still get the extra cushion they needed. Since I am not an attorney, part of the research I did included speaking with our legal advisors. This is how it was explained to me To write a prescription: “Inject 25 units subcutaneously at bedtime” when the person is only doing 10 units is a false statement. “A misrepresentation to gain ‘extra’ benefit from the insurance company.” Even though this is not then intent behind overstating insulin usage, the laws don’t take that into consideration. A provider is committing insurance fraud for writing it that way and the pharmacy is committing insurance fraud for filling it that way. The same is true if a person misrepresents what they are using (and the doctors and pharmacies are no less culpable just because they didn’t know. They are expected to know because the pharmacy can see how often they are filling it and the prescriber should know how often they are having to write the prescription.)
What I said that it may be why doctors are reluctant to write “inflated” prescriptions part of that was my opinion. The part about doing so knowingly being fraud, again that was what I was told by our legal advisors.
The part about doctors not be legal experts and things not dawning on them, that is my opinion based on experience.
With regards to clocking your refills. I can assure you that it is definitely happening and not just on prescriptions. They monitor whether you have had a recent diabetic eye exam, a recent hemoglobin A1c, blood pressure check, whether you are on a statin, whether you’ve had your kidney function checked. I can’t say that every single plan across the US does this but the big players typically do. Sometimes they want a response and sometimes it’s an FYI to the doctor, kind of like…“are you doing your job? This person hasn’t done this yet.” Then you have the yearly “quality measures” and “risk management” where they want a complete copy of people’s labs, proof of diabetic eye exams, there is a whole list of things. (This is not on everyone, I’m not quite sure who gets picked. Medicare patients, if they are on a MedAdvantage plan, definitely. The plan has to justify to Medicare what they’ve paid out on Medicare beneficiaries. But it isn’t just Medicare).
Before you ask, your privacy protect doesn’t extend to those paying the bills. That being said they are limited only to physical documentation of the time period that they are providing you with insurance coverage.)
My “favorite” is when the insurance companies send: “Your patient didn’t fill their prescription for “X” between the months of 01/01/2018-02/28/2018 (example dates)” Well duh, person gets a 90 day prescription and didn’t need to fill between those dates. (They did finally stretch their dates out after a year+ of this).
As I said above, when I was told it was insurance fraud part of what I wanted to know was how could we do it so that it wasn’t insurance fraud. The solution is actually very simple: “Don’t make a blanket statement.” Don’t say: “Inject 25 units subcutaneously a day” Use the phrase “Up to” then you are indicating that the person may be using that much but they may be using less. It varies. You can’t grossly overestimate it like saying uses up to 75 units a day" because then the whole “fraud” question comes into play again.
