There are many ways that your program can be manipulated at the pharmacy level (retail or specialty pharmacy). It doesn’t take much for an experienced pharmacist to get around your established program rules if they are determined to do so. Your business rules can leave the door open for experienced pharmacists to twist your program rules through the outdated NCPDP system to the detriment of your program and for the enrichment of the pharmacy’s wallet.
Now with the advent and marketing of “cash cards”, it’s not difficult to miraculously change an uncovered patient into what appears to be a commercially covered one, thereby providing the patient access to your copay discount. These patients are also the most likely to max out your very generous copay program cap.
Today, taking more money out of your copay program than what the brand expects is a very simple thing to do. If pharmacists want a higher payout to the pharmacy, they just need to raise the retail price entered on the claim, or they could just enter the usual and customary price. Or, they could try to submit the claim twice at slightly different times. The fact is that there are many different things pharmacies can do to increase their payouts if they are determined to do it intentionally.
Another issue is pharmacists who are not trained in entering copay claims and, as a result, they make “honest” mistakes. However, based on what I’ve seen, 95% of the time, the “error” results in a higher payout for the pharmacy, not a lower one. Coincidence? Probably not, but you will never know about this and be able to stop this type of activity without auditing your copay claims.
In addition, there are no checks and balances currently available to ensure purchases have been made before claims are submitted. The current system actually allows claims to be submitted for payment without the pharmacy ever having purchased the product. That is an invitation for fake pharmacies with fake patients to try and grab some of your budget. If they do try, there is a high likelihood they will be successful.
These types of pharmacy activities should be checked…frequently! And…it’s not something that your copay vendor can do at the point of sale. If they could, it wouldn’t be happening in the first place.
For many brands it’s not the out and out fraud that kills their budgets – the bulk of the increased cost comes from the “little bit higher payment here and there” that occurs as claims are incorrectly processed.
Think of it as trying to stop a 1950’s car from being stolen in today’s internet age. Spend a few minutes on the internet and you will find all one needs is a coat hanger and a screw driver and the car is gone! When the pharmacy systems were developed there were no copay programs and, as a result, there are very few mechanisms in the current process to stop the incorrect processing of payments and/or outright fraud.
Brands spend millions of dollars on copay programs, so it just makes sense to do copay claims processing audits once per year for checks and balances. I’m not talking about a “vendor audit”, I’m talking about pulling down every claim and having an objective 3rd party with expertise in this area examine them and let you know where the issues in your program are.
Just like your annual health check-up, the faster you find any issues, the faster you can make corrections. That makes for a healthy program. Remember you can’t treat the condition effectively until you know what it is.