Maybe that’s my problem. That is my jurisdiction. (9th circuit court)
This doesn’t work. The fact that you keep repeating it is quickly convincing me that you have no idea what you’re talking about.
This is about insulin.
What is also NOT FRAUD is whether I CHOOSE to use our insulin in a SYRINGE or a PUMP. That ALSO is NOT FRAUD.
Regardless of your opinion.
And I am getting overheated and must check myself out before the Admins tell me to take a break.
I don’t mean if you are actually using 25 units. I mean use the phrase “up to” for when over stating the amount. It works all the time here. I have dealt with more prescriptions and more insurance companies than you could ever deal with in your lifetime. I can’t say I have seen it all because the insurance companies are always surprising me. If it doesn’t work in your neck of the woods I’m sorry. I honestly wish I could help. I LOVE a challenge. Nothing makings me happier than finding a way to make things work despite the insurance company. It is extremely satisfying.
Well I know cvs Caremark, easily one of the three biggest pharmacies in The USA, maybe even the biggest will not fill insulin scripts with “up to”
Most doctors who know what they are doing don’t write insulin scripts for “up to” because they don’t want to have to redo them when they’re sent back…
Not sure how you would assume anything about my experience level dealing with pharmacies or insurance. I can assure you, it is substantial.
I always get my insulin prescriptions written for “up to” and it has always been filled that way. Man, now I am worried that pharmacies might not honor that anymore.
You are right and I don’t know your experience, I just know my background and it would be unusual. That is interesting about CVS Caremark. I have never had a problem with them but they are relatively new to our area (only last couple of years). It may have something to do with the state laws too but it may not. It depends on whether the plan is governed by state laws or federal laws (and that depends on what type of plan it is). I’m glad for the heads up though abt CVS Caremark. In all seriousness, I will save this information for later and be on the look out. There are so many caveats to the answer to some of these problems. The laws, the plan, the pharmacy, the doctor, the way the pharmacy understands the prescription, the way the insurance company understands the prescription. (One plan half the time can’t decide if it was talking about actual pens or mLs). First you have to find the cause of the problem and then you have to figure out what is going to fix it. Believe it or not, sometimes if you write the insurance company and explain that a person is a type 1 diabetic and may use as little as 5 units or may us as much as 50 units and that they are running short every month you may be able to get the plan to cooperate if you hit the right “buttons”. My guess would be that it is your actual plan that is the problem not the pharmacy (unless your pharmacy benefit manager is CVS Caremark in which case it both are the problem). Without more research and more details I can only make a guess.
Caremark is the mail order / pbm branch of cvs.
Anyway, my main point is that there is nothing fraudulent about a doctor prescribing the amount of insulin they see fit to adequately cover the patients needs. They make that judgement and write the prescription accordingly.
This is important, you have received 1 legal opinion. For virtually any law, written anywhere, I can provide you expert testimony that will hold up in court as just the opposite. If this were not the case, cases would not go to appeal all the way up to the supreme court. You also need to look at the intent of the law as well as how the law was written. That is why there are so many opposing views in courts for the same matter throughout the US.
One of the most important lessons I learned about 50 years ago as a business owner was that the fastest way to go out of business is to blindly heed the advice of your lawyer(s), accountant(s) or banker(s). Each person needs to listen to the professionals but then make their own risk assessment and do what they feel is legally and morally the best for themselves. Have you ever caught yourself totally illegally driving 57mph on a highway posted at speed limit of 55? Some people have a risk tolerance of 5 over the limit, others 10 and then there are those that don’t care and pay dearly in fines and insurance premiums.
So is it fraud if a woman has a prescription for birth control pills and she stops taking them?
I love your answer. It is so well expressed.
However, if you are to the point of a court case that means that somebody has decided you broke the law. Even if you feel you are right, you have equal chance that the courts and/or jury doesn’t agree with you.
Your analogy of speeding is a pretty good one. That being said, however, ridiculous or unreasonable it sounds, going over the speed limit is, as you said, illegal. They can, if they choose, hold you accountable even if it seems stupid to do so.
Do I think they are going to chase after a single individual for “inflating” a prescription for personal use…Not really…It seems rather silly like ticketing someone for 57 mph in a 55 mph zone. If a provider or pharmacy had a 200 patients doing it (with or without their knowledge), maybe. Especially if it is Medicare.
If you can solve the issue without all this personal examination why wouldn’t you? First find out why and then figure out what you can do about it?
A few years ago I started getting multiple complaints from seniors that their Part D plan was charging them two copays for their “30 day” prescription of insulin. After some digging I found out that, in our government’s infinite wisdom they created some 30 day supply for 30 day copay sort of rule. So, if a prescription lasted you 31 days or 35 days or 40 days, you have to pay two copays for that prescription. The really dumb thing, if the prescription was written for “90 days” and it exceed 90 days (say it lasted 118 days) the pharmacy can do an override for that and explain why they are giving you over the 90 days supply (basically that they can’t give you exactly a 90 day supply because of the package size) but they didn’t allow for it with 30 day prescriptions. We found ways around it but I also looked up the list of senators on the Medicare committees and called up either the one in charge or the one closest to me, I don’t remember which and asked them if it was true that Medicare had this thing about 30 day supply for 30 day copay and if it goes over that you have to pay two copays. The gentleman was actually kind of smug about it. “Of course. Why wouldn’t you have to pay two copays if it exceeds 30 days?” So I asked him: “What about insulin? It comes in a 10 mL vial or a box of 15 mL pens (that was back when insulin pens only came in 15 mL box). If a someone is on 35 units of insulin a day. That single box of insulin will last 40 days. You can’t break up a box. (Technically a pharmacy can break up a box but the vast majority where I live, won’t. Nothing says they can’t and nothing says they have to). I said what about inhalers or lotions or creams or gels. Are we supposed dump a little out so that it equals exactly 30 days?” The response word for word: “Well, we didn’t think about that.”
I haven’t gotten complaints about it in about a year or so. I don’t know if someone got around to “thinking about it” or if it isn’t as big a problem or if it is because Medicare has gotten REALLY big on 90 day prescriptions (again, at least in my neck of the woods. I don’t know if it is national or not because Medicare does things on two levels: National and Local)
This discussion seems to have gotten deep into the weeds.
The question of whether taking actions to allow ones self to build a reasonable stockpile is insurance fraud I believe is a matter of judgment. I have not heard of anyone being prosecuted for building said stockpiles. Technically it may be fraud but until they start dragging us diabetics before a judge does it really matter.
For better or for worse, the pharmacies (not the docs) are the most likely ones to profit and/or be found liable for fraud for overfilling prescriptions. Insulin-related example - just “rounding up to the whole pen box” - costing Walgreens a quarter BILLION dollars in the link below. It is hard to blame the pharmacy if a poorly worded prescription gives them the heebie-jeebies.
Nah, only if she stops having sex. /s.
If no one can point to cases of fraud convictions for having life-saving supplies on hand, then IMO, it isn’t even a matter of judgement. It’s a matter of prudence. Who in the heck would voluntarily screw themselves out of a proper amount of supplies so that were there a catastrophe, they wouldn’t have enough supplies to get by for at least a month. Or simply because of insurance or vendor delays.
I’m MDI and when asked what my dosage is I always tell them the amount when I used the most - which most recently happens to be when I was prescribed Prednisone steroids last year. My last 90 day order resulted in plenty of Lantus and almost 2ce the Apidra I need. IMO it makes up for the screw ups that had me using Humulin when the expensive crap ran out.
I don’t think it is so wrong to over estimate, my endo has done that for years, by atleast 1 or 2 vials per three months. I have built up a pretty good stock of insulin like that. I think the endo should inflate your usage by a little.
Where I live we don’t have to tell the Dr how much we use, and if we do, we certainly don’t have to ration supplies, that’s unthinkable to me! No human should have to live in fear of medication supply problems, that’s a dystopian nightmare. I wouldn’t wish that on my pet let alone another human being.
I’m just going to throw my two cents worth here. For years my prescription said take as needed. Back than, I guess it wasn’t as important to insurance companies to know how many units I was using.
My current script calls for 70 units daily via a pump. Now do I use 70 units a day? No but here’s the kicker some days I have.
This is my huge, huge frustration when a doctor asks me how much insulin I take each day. I just want to scream! Every day, I mean every day is different. I have been tracking daily amounts for the past two weeks for a clinical trial and none of those days are the same. Everyday I am taking a different amount.
With diabetes you just never know! How can anyone possibly know how much insulin they will need for the upcoming month? So do a I have a cushion? You bet! Because I never know! Maybe when I have family in town and I eat everything in sight, that 70 units might not make it. Everyone of use makes the decision each and everyday how much insulin to take. It’s my call, not my doctors or my insurance company. And if I have to have my doctor write the prescription for a little extra, that’s what I have him do so I am safe at all times. Nothing would freak me out more than having only one bottle of insulin in the refrigerator.