By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
AdvimedPro
June 20, 2023
Over the last few years, a disturbing trend on how insurance companies manage infused or injected medications has been growing: forcing medical offices to obtain them from a mail-order pharmacy.
Aimed at saving costs (theirs, not yours!), it affects inexpensive B12 injections, complex chemotherapy infusions, and anything in between.
The American Medical Association and various organizations have decried this move, raising serious concerns about safety, treatment accessibility and liability.
1. The trend
Insurers are shifting the financial burden of many infused or injected medications to patients. These were always purchased by the medical practice where treatments were rendered, and billed under the "medical" portion of your policy, along with the cost of administering them to you. Bought from reputable vendors, they were shipped under optimum conditions, guaranteeing safety and timeliness.
Now, drugs must be ordered by offices through designated mail-order companies under the "pharmacy" benefits of a policy. They are shipped to the office ("white-bagging") or to patients directly ("brown-bagging"). If so, patients must then deliver them to the office or keep them somewhere safe before a home health agency shows up to administer them.
2. What's the big deal?
There are many unsettling aspects to this business model.
• Administrative hurdles: Offices have to request two authorizations: for the treatment itself ("medical" authorization) and one for the drugs ("Pharmacy" authorization). This means delays and added work.
• Pay up now! Before a shipment is sent out, the mail order pharmacy requires full payment from the patient: no monthly payments or bills after the facts, as with your doctor.
• Uncertain scheduling: your next treatment becomes dependent on a delivery not necessarily your established schedule. Coordinating ordering (can't be too early), delivery (not on weekends) and administration may test the staff's (and your) patience. Shipments can be mis-delivered, stolen, or left unattended too long so as to risk spoilage.
• Provenance: a big issue raised by the AMA: the origin of drugs cannot be traced further back than the mail-order company. Where, when and from whom were the drugs purchased? The office may end up using drugs manufactured abroad and/or not inspected in the US. While the overall US supply is usually safe, recalls of compromised batches occur.
• Shortages: especially since Covid, more and more drugs are in short supply. Offices would "stockpile" whenever possible or purchase expensive alternatives to avoid delaying or canceling treatments (at same cost to you). Mail order pharmacies or your local drugstore may take longer to fill backorders now.
• Safety: Can you trust the drugs that sat on your porch until you got home remain safe and effective? Is your fridge too cold or not enough for storage? How long was the package left in a delivery truck without proper handling? How about along the way?
• Liability: is your Doctor legally responsible for any product injected into you, when he has lost control of the process? Will his malpractice insurance cover such claims? Whose fault is it in case of a negative outcome due to spoilage?
• Costs: even if you have met your yearly share of cost on the "medical" side, you may have to pay separately for "pharmacy" items, something that was included before.
3. What can you do?
If your physician must use his/her own supply, and the insurance refuses, an appeal can be filed explaining any risk of using a brown or white-bag drug (i.e you cannot store it safely, access to your PO Box is limited, drug is too sensitive to be sent via mail or UPS...)
Ask your insurance if shipments can be sent directly to the office instead of your home for safer handling. Threatening to hold your insurance liable for any adverse reaction may help.
In some cases, paying cash might be the way to go. B12, for example, costs a few dollars. Offering to pay the office directly will save time and efforts, and should be accepted by the grateful staff.
In conclusion:
Be pro-active when your doctor prescribes an infusion or injection. Call your insurance to find out every detail, and your estimated or final cost.
Talk to the staff about any authorization guideline, and whether brown or white bagging set-ups will even be accepted. Many offices may not, citing legal liability and malpractice insurance constraints. An alternative arrangement administration at your home or at an infusion center may then be in order.
Martine Brousse, the "medical bill whisperer" is a Patient Advocate and Certified Mediator located in CA and the founder of AdvimedPro, which she started after 20 years as a billing manager for physicians.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2023
@ the medical bill whisperer 2023