It's OK to Sue the Pharmacy when the Insurance Denies a Claim?

The Supreme Court of Massachusetts has ruled that a family can sue Walgreens over the death of a family member after insurance denied a claim.

The Massachusetts Supreme Judicial Court wrote that Walgreens had a "limited duty to take reasonable steps to notify both Rivera and [her doctor] of the need for prior authorization each time Rivera tried to fill her prescription." The pharmacy is not required by law or regulation to facilitate the pre-authorization, but "it is evident that they have some role in furthering the well-being of their patients, and are well suited to assist patients with certain issues regarding their medication," the court wrote. "The skill and knowledge of pharmacists today involve more than the dispensing of pills." See LINK.

First, let's talk about a "Prior Authorization."

It happens almost every day. A patient comes to the pharmacy with a prescription. We type it into the computer and send it electronically to the patient's prescription. It gets rejected. What we see on our end is "Prior Authorization Required."

"But my doctor authorized it!" people will wail, not understanding what that means.

What it DOES mean is that the insurance will not pay for the medication, right now, without having the physician's office call the insurance and answer specific questions as to why the patient needs this medication.

In most cases it is because the actual medication itself is not on the list of medications that the insurance covers (called a FORMULARY). Most of the time they don't want to pay because it is expensive. In most cases it is reasonably prudent to try a less expensive medication for the patient's condition first, before going with the one that was prescribed. 

At the pharmacy end, we don't know WHY. All it tells us is "Prior Authorization Required." At my pharmacy we issue an electronic message which is sent to the prescriber. We also print a form and fax it to the physician's office.

It's a pain for the pharmacy. It stops the process of filling prescriptions and creates additional paperwork for us. At the physician end, it's a pain as well. Some physician offices have ONE person that just deals with prior authorizations all day long.

At my pharmacy, we try other options to get the medication paid for the patient. We try discount cards and other methods. If it is not too expensive, the patient often opts for this choice rather than wait for the prior authorization. A prior authorization is not an instantaneous process. We tell people 48 to 72 hours and admonish them to call their physician to "speed it along." The physician works for the patient, NOT the pharmacy, so this is often a good thing to do.

In some cases, when all else has failed, the patient will say, "Well, I have to have it. I will just pay for it whatever the cost." And in a life-threatening situation, that's what I'd do if it was my child. If it's particularly expensive, we'll offer to fill it for a few days supply until the physician office calls the insurance or prescribes an alternative medication.

In the Massachusetts case, Walgreens did nothing wrong. They sent off the request to the physician electronically. They informed the patient. They told the patient to contact the prescriber too. Regardless of whether the physician's office dragged their feet getting the prior auth completed has nothing to do with the pharmacy.

Suppose you go to your favorite restaurant. You eat a delicious meal and the waiter brings the check. You give them your credit card but YOUR credit card company refuses to pay the bill. Is it the waiter's responsibility to get your credit card company to pay for the meal? Of course not. That's ludicrous.

At the pharmacy, we bill insurance IN BEHALF of the patient as a courtesy. We're not obligated to pay the bill. The patient pays the bill. That's the way the world works.

In the Walgreens case, they followed a typical protocol. The "skill and knowledge" of pharmacists stops at pharmaceutical knowledge. We're not billing experts, nor are we "prior authorization" experts. Further, this story doesn't even begin to address why a common medication like Topamax isn't covered by the insurance... and more likely, was being handled by a Pharmacy Benefit Manager (PBM). PBMs face more and more scutiny because they're supposed to save the insurance company money but often don't. See LINK.

I don't know how this is going to end up, but the pharmacy is not at fault here.