Providers Behaving Badly, Part 2

Guest Blogger "Roland" offers us an inside look at how some health care providers "game" the system for monetary gain, often at the expense of the patient. In Part 1, we learned that many providers sell medication at a greatly increased price as an additional "profit center." Today, we see first hand how this impacts their patients:

Unknown to us, the patient had another chemotherapy session slated for this past Thursday. She called us at 8 a.m on Thursday (her treatment was at 10), crying that the facility was refusing to treat her unless we kowtowed to their demands by then.

My manager immediately got onto the phone with our PBM, who attempted to call the facility. They would not return my manager's calls. She then called the provider herself. They also would not return her calls. Finally, she was able to get hold of the provider's account manager, who was forced to admit that the real reason behind their not cooperating was the cost, *not* because there was no longer any real concerns about the PBM or how the drugs were shipped. She actually admitted that it was about the cost.

My manager quickly stated "I think what we need to do is for you to tell us how much you'll be charging for the drug and then we'll take it to our PBM and see what they would reimburse for it. If what you're charging is lower than that...we'd be foolish not to accept your billing."

Which, unbeknownst to the facility, we already knew they were billing well above AWP. They had put the NDC number [National Drug Code Directory, a list of all drugs manufactured, prepared, propagated, compounded, or processed by drug manufacturers] on one of their claim submissions for a drug billed with a miscellaneous HCPCS code [Healthcare Common Procedure Coding System, a Medciare initiative to identify various treatments and medications]. They charged $450. The AWP was $210. I doubt that was a fluke.

The account manager stumbled and said she'd have to run it by her superiors, and as of now that's where the situation stands. They did, however, give the patient her treatment that day, so that's something.

All through this, however, the facility was painting us out to be the bad guys on this to the patient. That we were being unreasonable and all the usual insurance stereotypes. The fact is, we were trying to bend over backwards to work with the facility to ensure that the patient got the maximum benefit allowable under her plan. Which is a contract. The facility seemingly won't accept less than what they normally mark a drug up for, yet the insurance carriers are supposed to pay above and beyond what the contract would allow because of that?

I take no pleasure in the fact that this poor woman is having to deal with this when she's going through chemotherapy. It's been on my mind all weekend. Yet, if physicians and facilities weren't continuously marking up the costs of their services well beyond a reasonable margin of profit, carriers wouldn't have to do things like this, either. I've been running AWP on many chemotherapy claims that come in, some from well-known cancer treatment facilities, and the drugs are sometimes marked up $10,000 above AWP. AWP which is already artificially inflated and was the subject of a lawsuit against the manufacturers of some of these drugs.

So this is the other side of the story whenever you hear about the evil insurance companies. There's not one person in our office who didn't feel for this poor woman. However, we are also obligated to do our jobs and make sure that the terms of the contract apply. That's what insurance is. It's not an ATM card doctors and facilities can swipe anytime they want reimbursement.

Until we start holding them accountable for some of their actions...national health care would be a complete and utter joke.

Thank you, Roland, for your insights and information. It truly underscores the distinction that must be made (as we do so often here at IB) between health care and health insurance.