ALBANY – Peter Levis, Supervising Pharmacist, and George Rontiris, Owner, of Titan Pharmacy in Astoria Queens are trying to do the right thing, but New York law does not offer them the ability to be reimbursed if they provide authorized medications to injured workers when the system for pharmacy benefits fails the injured worker due to bureaucratic reasons.
Titan Pharmacy provides the medication that injured workers need in accordance with New York State Workers’ Compensation Board guidelines when they need it, if the final online authorizations are held up for administrative reasons. However, in New York the insurance carrier’s network pharmacy is mandatory. If the authorization is denied online and the pharmacy dispenses the medications to be paid later, the insurance carrier can deny ultimate payment because the pharmacy did not go through the network, even though the network had already denied the medication that should be authorized.
This system has led to situations where patients are denied their post-operative pain medications through the networks and if the pharmacy dispenses them at risk and bills the insurance carrier directly, the pharmacy is then denied for not going through the network! These Catch 22 shenanigans should not be allowed to stand in a NYS Workers’ compensation system that is supposed to return workers to health so that they may get on with their lives and their jobs.
“When the system fails to authorize medication to the injured worker for very specific reasons, such as denial of pain medications for a postoperative patient whose surgery has already been authorized, the patient basically has no recourse,” said Peter Levis. “In our experience this is an administrative error, so we provide the patient with the medication and have to hope that we get paid on the back end. We have essentially lost this ability.”
The bill, A1013B, is supported by the NYS AFL-CIO, NYS Injured Workers Bar Association and PSSNY. It was sponsored in the Senate by Jessica Ramos and was overwhelmingly passed. In the Assembly, the bill is sponsored by Harry Bronson but stuck in the Labor Committee. Titan has heard that perhaps it was held up because of cost, even though costs are controlled by a variety of methods in NYS WC, including a fee schedule that limits what can be charged and a formulary that determines what medications can be authorized; however, the Assembly has not provided them with an exact reason. The bill was moved out of committee and the Assembly in the past and would affect roughly 5% of the injured workers in the system.
“The lack of oversight and the monopolistic approach of the current system has led to little or no accountability. Abuse has occurred because of the lack of checks and balances. We have situations on a regular basis where the prescriber has taken the time to obtain authorization for a medication directly from the NYS Workers’ Compensation Board Medical Portal website and the medications are still denied online by the network! Injured workers should not have to pay the price for bureaucratic errors. This is a bill that would allow access to required medications for the injured workers who have fallen through the cracks when the system fails them.” said George Rontiris.
Bill A1013B still gives insurance carriers using network pharmacies the right to mandate that all prescriptions are attempted to be processed through their chosen network. If the system works as it is supposed to, then this bill will effectively have no impact; it is only when the system fails the injured worker that they would be able to access out of network pharmacy medication, and even then, only when they can find a pharmacy willing to fill at their own risk, something large chains stores never do. This is where the independent small pharmacies of NYS can step up and help injured workers.
“We are taking all the risk to make sure injured workers are provided the medications which are indicated for their injuries and which should speed up their recovery and return to work. Right now, the current law makes no allowance for failures on the insurance carriers’ part, and it is always the injured workers who pay the price. The law also does not allow for pharmacies to carry litigated cases at their own risk where the carriers are not authorizing any treatments at all, even though NYS WCB regulations allow for exactly that. This bill is about providing injured workers in NYS a safety net when the system fails them.” said Peter Levis.