Category:

Pharmacy Billing Basics: Know Your Payor!

October 10th, 2018 by

pharmacy billingBy: Michael Silverman

In giving consideration to whether healthcare regulations apply to a proposed course of conduct it’s absolutely vital for a pharmacy to know its payor! This is especially so in the context of patient marketing and the various regulatory prohibitions on paying for healthcare referrals. Unfortunately, some pharmacy owners remain a bit mixed up about who the ultimate payor is for the medications they dispense, and, depending on that pharmacy’s billing operations, such mistakes can have devastating consequences.

A large part of this confusion might be attributed to the fact that in most instances, a pharmacy is not billing the ultimate payor directly (unlike a DMEPOS provider that may be directly submitting claims to Medicare Part B), but rather, the pharmacy is billing an intermediary entity called a Pharmacy Benefit Manager (“PBM”), which is usually a commercially run entity (non-government owned) that manages and adjudicates claims on behalf of health insurance plans that cover pharmacy benefits. read more

Pharmacy or DME: The Time is Ripe to Become Both

August 13th, 2018 by

pharmacy dmeBy: Michael Silverman

People looking to enter the direct-to-consumer medical supply business often question whether becoming a pharmacy or durable medical equipment provider (DME) is a “better” endeavor.

Now, more than ever, due to industry changes and because of the synergies between the two, the answer is “ become both.”

Think about it. read more

Independent Pharmacy Owners: Trump Proposal May Improve PBM Issues

July 5th, 2018 by

independent pharmacy ownerBy: Michael Silverman

President Trump has stated that one of his greatest priorities is to reduce the price of prescription drugs. Alex Azar II, secretary of the Department of Health and Human Services (“HHS”), believes that while the United States’ system enabled it to become a world leader in the development of cutting edge drugs is also one that has not prioritized the needs of its own citizens.

On May 11, 2018 Trump directed his Administration to fix the injustice of high drug prices to ensure they come down, and unveiled his “blueprint” to put “American Patients First” though a 44 page document released on HHS’ website.

Pharmacy Benefit Managers (PBMs), previously largely unknown ‘middlemen’ in the U.S. pharmaceutical industry, whose impact on our healthcare system is just slowly beginning to emerge from the shadows, have been taking a lot of flak from independent pharmacy owners, politicians, and the media for being a cause of the high drug costs that the Trump Administration has vowed will be reduced.

read more

Prescribing & Dispensing Controlled Substances: Legal Update

June 5th, 2018 by

dispensing controlled substancesBy: Michael Silverman

A new law has been passed in Florida that pertains to prescribing and dispensing controlled substances. On March 19, 2018 Governor Scott signed HB21, which becomes effective July 1, 2018. Intended to address the growing nationwide opioid epidemic that has also greatly affected Floridians, among other requirements, the new regulations establish: read more

Telemarketing Compliance: Legal Considerations Before You Call

May 15th, 2018 by

telemarketing complianceBy: Michael Silverman

Miami resident Adrian Abramovich certainly wasn’t laughing on Thursday May 10th, 2018 when the Federal Communications Commission (“FCC”) levied a $120 MILLION dollar fine on him for his alleged involvement in an illegal robodialing campaign. FCC Chairman Ajit Pai stated that Abramovich did not dispute that he had placed more than 96 million telemarketing robocalls over a three month period in 2016 without the recipient’s consent. Furthermore, Chairman Pai stated that Abramovich’s telemarketing campaign utilized caller ID “spoofing” which masks the calling party’s true phone number and causes the recipient’s caller ID to indicate that the call was being made by a local number. Abramovich’s telemarketing activities allegedly violated a variety of state and federal regulations; caller ID spoofing, for example, is expressly prohibited by the Florida Telemarketing Act, § 501.616(7).

With the record-breaking fine imposed on Abramovich, the FCC is sending a loud and clear message that it will not tolerate those individuals or entities that violate telemarketing laws. Any person or business engaged in telemarketing (be it a healthcare provider with a single telephonic sales representative or a business devoted to telemarketing with a 100 person call center) must heed the FCC’s unsubtle hint that enforcement activity of telemarketing laws is only heating up. read more

Florida Telemarketing Law: What You Need to Know

May 14th, 2018 by

florida telemarketing lawBy: Michael Silverman

Like it or not, telemarketing is a huge component of American businesses, and the healthcare industry is no exception. Many insurance companies, physicians, medical equipment and pharmacy providers heavily rely on telemarketing to expand their client base.

Take a moment to reflect – are you engaged in telephonic marketing or sales? Be it a healthcare businesses’ own internal based sales team or a third party providing such services, many individuals and entities are telemarketing and don’t even realize. If conducting telephonic sales either out of a Florida based location, or if calling into Florida, then listen up! There is a Florida telemarketing law that requires all such marketers to register for a telemarketing license or file for an exemption therefrom. While it’s not a new regulation, it’s one that is often overlooked and one that carries serious consequences for non-compliance.

What am I talking about?

Florida Statute Title XXXIII, Ch. 501 §§ 501.601 through 501.626, or more colloquially known as The Florida Telemarketing Act.

BEFORE doing business, The Florida Telemarketing Act requires individuals or entities looking to conduct telemarketing activities within the State to either (1) obtain a Commercial Telephone Seller Business License, as well as to license its individual sales representatives, or (2) have an approved exemption from such licensure on file. For the purposes of the Florida Telemarketing Act, this includes individuals/entities calling either into or calling out of the State! Unwanted telemarketing calls are one of the largest sources of consumer complaints in America; an individual or entity engaged in telemarketing will not “fly under the radar.” A called party will inevitably file a grievance with the state or federal government over telemarketing calls. If the activity falls under Florida’s jurisdiction, regulators will investigate and will penalize those persons or businesses involved if they are not adhering to the regulations outlined in the Florida Telemarketing Act. So what’s required to become licensed or exempted?

The license or exemption is issued by the Florida Department of Agriculture and Consumer Services – Division of Consumer Services (“FDACS”). A commercial telephone seller must obtain a license from FDACS, in accordance with §501.605, or have an exemption from such licensure on file, in accordance with §501.604.

Option 1 – Apply for the Commercial Telephone Seller Business License read more

So, You Want to Be in the Pharmacy Business? Building from scratch, acquisitions & other considerations.

March 29th, 2018 by

pharmacy businessBy: Michael Silverman

Like many entrepreneurial endeavors, owning a pharmacy requires careful planning and an astute risk versus reward analysis. However, unlike other industries, venturing into a healthcare business brings with it an entire new world of regulations, and rightly so. Pharmacies don’t sell widgets they sell prescription drugs, and to people whose well-being depends on it being done correctly. As such, there’s a host of state and federal laws a pharmacy must abide by, intended to safeguard patients and the healthcare system as a whole. Don’t let regulatory hurdles alone serve as an insurmountable deterrent from entering into what can be a profitable and fulfilling profession; proactive compliance is the key to success! Here’s an overview of the general steps necessary to become a pharmacy owner, be it from scratch or by acquiring an existing practice. For the purposes of this article, let’s assume it’s a community/retail pharmacy that will be located in Florida.

So what’s better – building from scratch or buying something that’s already out there? Typical lawyer answer – it depends! But I won’t stop there; here are some considerations that must be taken into account to make a proper decision: (1) how quickly does the business need to be up and running? It’s typically a faster process to commence business by acquiring an existing pharmacy rather than buying one, but that depends on (2) what is out there in the current marketplace? If a stock acquisition, all of the known and unknown liabilities will be inherited by the new owner; proper due diligence on the pharmacy’s past is essential. read more

Pharmacy Audits: State of the Industry & Knowing Your Rights!

March 19th, 2018 by

pharmacy audit pbmBy: Michael Silverman

Pharmacy Benefit Managers (“PBMs”) act as the intermediary between insurance companies and pharmacies. PBMs contract with insurance companies on one hand and with pharmacies on the other, connecting the two so that an insured’s pharmaceutical claims may be processed at the rates set forth in the agreement between the PBM and supplying pharmacy. PBMs are paid on both sides of this transaction – by the insurance company for managing their insureds’ benefits – and by the pharmacy for processing the claims that are submitted. Processing claims for private, state, and federally funded insurance programs, PBMs play an integral role in vast majority of prescription drugs dispensed in the United States.

Part of a PBMs function is to audit a pharmacy’s claims to ensure that the claims submitted are in compliance with the PBM and insurance companies’ requirements.

Typical audits come primarily in two forms (1) desktop audit; and (2) field/on-site audit. A selected pharmacy usually will receive a letter or fax from the PBM informing an audit will be taking place. read more

DMEPOS Medicare Coverage & Reimbursement

March 14th, 2018 by

DME medicareBy: Michael Silverman

Providers need to comply with all the Medicare ‘red tape’ but need not let fear of non-compliance inhibit their practice from offering Durable Medical Equipment Prosthetics & Orthotics Supplies (“DMEPOS”) to Medicare beneficiaries.

Here’s an overview of the steps providers need to take to enroll as a supplier of DMEPOS with Medicare to be eligible for Part B coverage and reimbursement: read more

Chiropractic Practice Expansion: The DMEPOS Licensure Process

March 13th, 2018 by

DMEPOS LicenseBy: Michael Silverman

Adding Durable Medical Equipment Prosthetics & Orthotics Supplies (“DMEPOS”) to a Chiropractic Practice is a great way to not only increase revenues, but most importantly it is a great way to increase overall patient satisfaction and care.

Providing patients with easy access to DMEPOS allows for more comprehensive care, enabling providers to help further stabilize injuries, maximize patient recoveries, and minimize patient down time. Many existing patients are already buying and utilizing DMEPOS such as back braces, so there is an opportunity to provide that additional supervision and care through an existing practice.

Examples of DMEPOS that would complement a Chiropractic Practice and which patients are likely already using: read more