Niche Pharmacies and Prescription Drug Fee Reimbursement in the Texas Workers’ Compensation System

Among the current trend issues in medical payment dispute image resolution circles is pharmacy repayment. Niche pharmacies have moved into the Texas workers’ payment market. These pharmacies only market and provide services to injured workers. They will do not fill medications for non-workers’ compensation patients. Some are national suppliers to injured workers, and more are more local, servicing their surrounding communities. Regardless of their size and the scope of their market(s), they are all coping with one common cost dispute in Texas – a proxy for the pharmacy’s usual and normal fee. dexilant coupons 2017

The maximum allowed reimbursement (MAR) for pharmaceutical drug drugs is placed by Split Rule 134. 503(a). Beneath the Rule, the SCAR is the lesser of:

1. The provider’s typical and customary charge;

2. A formula based upon average wholesale price, a transformer and a dispensing cost;

or, 

3. an agreed or contract price.

If perhaps there was an agreed or contract price, then there would be little need for litigation over a single prescription invoice. The recent cases being set before the Department are disagreements over a pharmacy’s usual and traditional charges. The pharmacies are billing a sum greater than the formula-based MAR so that the formula-based SCAR is paid in every case.

There are numerous factors in establishing the cost of a product – some unique to the workers’ compensation system. In Medical Dispute Quality case number M4-02-5033-01, the pharmacy argued that this experienced to factor into their price the unique aspects of: verification that says relate to compensable office injuries, identification of providers providing coverage and their adjustors, the preparation and submissions of manual statements forms, verification of membership and enrollment for compensation, and the extension of credit pending payment by insurers that is not required until sixty days after the submission of “clean statements. ” Considering that the formula-based MAR uses réformers ranging from 1 ) 09 to 1. twenty-five with only a $4. 00 dispensing fee, it can be easy to understand how usual and customary prices can be established that exceed the formula-based SCAR.

If these cases included large pharmacies with high volume non-workers’ compensation services, then the operating costs of providing workers’ compensation-related services would be balance by the efficiency and volume of the non-workers’ compensation-related services. Prices would probably are likely to be lower in that scenario. Although that is not the case with these specialized niche pharmacies marketing only to injured workers. In order to they can get reimbursement is to navigate complex refund systems that require more complex knowledge, greater time and longer delays of payment than non-workers’ settlement systems.

Regardless of the justification (or lack thereof) of the amount paid established by these niche pharmacies, it is not why the pharmacy charges a particular amount, but whether it can establish that it does usually charge a particular amount that is important. Rule 134. 503(a) specifically provides that one of the comparison procedures for the selection of the MAR value for prescription drugs is the provider’s usual and standard price. The question is not if the usual and customary price charged is justified. Fit whether the price charged is actually usual and customary; can it be the regular price billed by that provider?

This kind of is the crux of the dispute in these instances. In non-workers’ settlement situations, many of the larger national pharmacies have negotiated contract prices well below the Texas formula-based MAR. These niche medical stores that only provide services to injured personnel have not. So insurance companies are seeing workers’ payment providers obtaining a higher reimbursement for a particular prescription than it usually pays in non-workers’ payment situations. This resulted in efforts to curb these specific niche market pharmacy’s cost reimbursements.

Presently there is merely one Medical Competitive Case Hearing to date on this issue, reported as Medical Contested Case Seeing and hearing Number 10169, and it went through the system as Tracking Number M4-07-4069-01. In this case, the carrier made an incomplete reimbursement and urged two major causes why additional compensation must not be paid.