In pharmacy, the insurance companies call themselves Pharmacy Benefits Managers (PBM). What do they call themselves over on your corner of the corral?
The ones who are paying, always dictate the rules, always. I know you are aware of this if you are in any of the medical professions. But pharmacy has been so fragmented during the last couple decades that the profession was easy pickin's for the insurance industry. Pharmacists are putting up with $4.00 fees on an $85.00 investment. That is just the average prescription. There are plenty of $4.00 fees on prescriptions costing hundreds of dollars.
In pharmacy, the insurance companies call themselves Pharmacy Benefits Managers (PBM). What do they call themselves over on your corner of the corral? Doctors should be holding all of the cards, but they are also being picked apart piece by piece. You bill a usual and customary of $100.00 and settle for $60.00. Usual and customary is BS. We both know that. By the way, the average wage for a medical doctor has declined almost every year for the past 6-7 years, as of the last time I saw any numbers. It’s all a game of leverage.
PBMs hire some slick clinical pharmacists to justify why they won’t cover certain medicines. Always very expensive medicines. I suppose that the insurance companies hire doctors or very good nurses to argue with you about if they will cover procedures or treatments or diagnostic tests.
How did we ever let this get out of our grasp? The insurance companies provide absolutely no medical care. None. Nada. Zilch. In the end, what the insurance companies do is take in $100.00, keep $25.00 for themselves and pay out the remaining $75.00. They have the leverage. We gave it to them.