ESI Reverse/Rebill

Pharmacies, listen up.

It has come to my attention that Express Scripts (ESI) is manipulating the MAC appeal system. Pharmacies across Tennessee are reversing and rebilling approved MAC appeals — exactly as required — only to be hit with lowered reimbursement and increased patient copays. In many cases, the difference is hundreds of dollars, not just a few.

Pharmacies are being forced to call patients — whose prescriptions are ready for pickup or already picked up — and tell them they suddenly owe more money because their insurance did not process the claim correctly the first time.

This is unacceptable, it is harmful, and it is not consistent with the intent of Tennessee law.

I am issuing an immediate  Call to Action for ALL Tennessee pharmacies.

What I Believe ESI Is DoingBased on consistent reports from Tennessee pharmacies, here is the pattern I believe is occurring:

• ·A MAC appeal is submitted

•  ESI approves the appeal.

• The pharmacy follows the law and reverses and rebills the claim.

•  Instead of applying the corrected MAC price to the original claim, ESI appears to:

o   Recalculate the patient’s deductible phase,

o   Reopen coinsurance,

o   Apply new plan-year rules, or

o   Reset the patient’s accumulator,even though the prescription is ready for pickup or already picked up.

This behavior looks like a phase shift or accumulator reset. The result is:

• Higher patient copays

• Lower pharmacy reimbursement

• Lower plan liability

  
  

While this pattern has not yet been fully vetted by regulators, the structure and intent of Tennessee law make it clear that PBMs may only adjust the MAC price during a MAC correction — and nothing else. Tennessee’s PBM rule requires PBMs to reverse and rebill “the claim upon which the initial appeal is based,” not to create a new claim with new benefit phases (Tenn. Comp. R. & Regs. 0780-01-95-.04(2)).Tennessee State Government

Tennessee’s patient-protection statutes prohibit higher or second copays, different copays within the same network tier, and financial penalties tied to pharmacy choice (Tenn. Code Ann. §§ 56-7-3120, 56-7-3121, 56-7-2359). Even if ESI is leaning on the fact that the law does not spell out every prohibited system behavior in IT language, they are using that silence to step around what the law clearly intended: to protect patients and pharmacies from this kind of manipulation.Tennessee State Government

Call to ActionTennessee law holds PBMs accountable — but only when we report what is happening.

To every pharmacy in this state:

• We must document this.

• We must report this.

• We must help patients report this.

• We must do it now — and do it consistently.

You do not need to submit twenty complaints. You need one to two strong complaints per plan (different BIN, PCN, and GROUP). Quality matters more than quantity. 

PBM complaints for change in R/R-->Steps for filing complaints.  Link to other blog post.

Pharmacies and other covered entities should use the Tennessee Department of Commerce and Insurance (TDCI) Pharmacy Benefits Manager Complaint Form to report this behavior. The online PBM complaint form is available here:

·       PBM Complaint Form (pharmacies/covered entities):https://www.tn.gov/commerce/insurance/pbm/complaint.html Tennessee State Government+1

Patients carry tremendous weight with regulators. Pharmacies should help patients file their complaints on the spot, using a store iPad, laptop, or tablet, and be willing to sit with them as they call their insurance and complete the TDCI complaint form or general insurance complaint form:

·       General Insurance Consumer Complaint Form (patients):https://sbs.naic.org/solar-web/pages/public/onlineComplaintForm/onlineComplaintForm.jsf?state=tnsbs.naic.org

We will not allow ESI to manipulate Tennessee’s MAC appeal system or use reverse/rebill to shift cost back onto patients and pharmacies. 

Potential safeguard against this……

I would like for pharmacies to understand that even though it is your legal right to reverse and rebill an approved MAC appeal, you technically do not have to to get the higher reimbursement.  

"(b) If the appealing pharmacy fails to reverse and rebill its claim pursuant to subparagraph (a), the PBM shall adjust the rate of reimbursement and make the payment(s) no later than fifteen business days after the PBM receives notice of the initial appeal."  TN 0780-01-95-.04 

This means that even if we do not reverse and rebill, the PBM still has to pay within 15 business days from the date the initial appeal was submitted.  (If you were requested to send in an invoice after initial appeal, the 15 days will start from the day you submitted the additional information.)

If you already have claims that were reversed and rebilled with a lower reimbursement rate and higher co-pay, PLEASE get the correct information from your pharmacy and the patient and FILE A PBM COMPLAINT.  (Attached more information) 

Here is the catch....tracking these increased payments without reverse/rebill will be tricky and time consuming.  Using whatever reconciling software, you can track when payments come from PBMs.  However, they may not come listed/tied to that specific prescription number, so be sure to look at any 'lumped adjustments'. 

 I encourage you to call the PBM asking for the confirmed payment amount and date of payment.  (Always be sure to keep documentation of a call with representative’s name, date/time, reference number for call and anything that was said during the phone call.).  If the PBM cannot show proof of payment that is an immediate external appeal AND PBM complaint.  Again, TDCI does not need hundreds of complaints stating the same thing.  File one PBM complaint and reference your external appeal.  (Remember, TDCI talks to Myers & Stauffer to follow up on PBM complaints.)