By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
AdvimedPro
February 19, 2025
Over the last few years, a disturbing trend on how insurance companies manage infused or injected medications has taken over: forcing medical offices to obtain them from their mail-order pharmacy.
Aimed at saving costs (theirs, not yours!), it affects inexpensive B12 injections, complex chemotherapy infusions, and anything in between.
The American Medical Association and various organizations have decried this move, raising serious concerns about safety, treatment accessibility and legal liability.
A. The Trend
In the olden days, infused or injected drugs were always purchased by the medical practice where treatments were administered, and billed under the "medical" portion of your policy (along with the cost of administering them to you). Bought from reputable vendors, drugs were shipped under optimum conditions, guaranteeing safety and timeliness.
Now, drugs must be ordered through designated mail-order companies called "Pharmacy Benefit Managers" or PBMs. These companies act as intermediaries between insurance plans, pharmacies and manufacturers, and are often owed by insurers.
You might know "Caremark", "OptumRx" or "Evernorth/Express Scripts".
Drugs are shipped to the office ("white-bagging") or to patients directly ("brown-bagging"). If so, patients are responsible to store them safely before bringing to the office or before a home health agency shows up to administer them.
While drugs such as chemotherapy, IV antibiotics, Bisphosphonates to treat osteoporosis or simple iron or B-12 were previously purchased by the provider administering them, they also were billed to and paid by the medical side of the policy. Drugs forced to be purchased through a PBM are billed to your Pharmacy plan benefits.
B. Are there advantages?
For insurance companies: It means savings on the medical side of your policy, while shifting costs to you through your pharmacy benefits. You would like have to meet a separate deductible and out of pocket share.
For PBMs: they are the biggest winners: they save money though manufacturers' quantity discounts, by setting their own prices, and by taking a seller's commission as a pharmacy. None of these financial windfalls are shared with patients.
For Medical Providers: they may welcome the ease and convenience of getting drugs without having to negotiate prices, find doses during shortages, or advance the cost while waiting (and hoping!) for patients to pay their balances down the line
Patients get to know the cost before hand: by having to cover the full cost of the drug before it is shipped.
C. Disadvantages:
•  Administrative hurdles: Offices may have to request two authorizations: for the treatment itself ("medical" authorization) and one for the drugs ("Pharmacy" authorization). This means delays and added work.
• Pay up now! Before a shipment is sent out, the mail order pharmacy requires full payment from the patient: no monthly payments or bills after the facts, as with your doctor.
• Logistics: your next treatment becomes dependent on a delivery not necessarily your prescribed schedule. Coordinating ordering (can't be too early or late), delivery (not on weekends or after 5:00pm) and administration (Oral version is OK but infused is denied) may test the staff's (and your) patience.
• Provenance: a big issue has been raised by the American Medical Association: the origin of drugs cannot be traced further back than the mail-order company. Where, when and from whom were the drugs purchased? Were drugs manufactured abroad inspected for safety in the US? While the overall US supply is usually safe, recalls of compromised batches occur.
• Shortages: especially since Covid, more and more drugs are in short supply. Offices would "stockpile" whenever possible to avoid delaying or canceling treatments (at same cost to you). Mail order pharmacies or your local drugstore may take longer to fill backorders, delaying your treatment.
• Safety: Can you trust the drugs that sat on your porch until you got home remain safe and effective? Is your fridge cold enough for storage? How long was the package left in a hot delivery truck without proper handling?
• Liability: is your Doctor legally responsible for an adverse reaction or injury to your health for a "bad" drug when he has lost control of the process? Will the malpractice insurance cover such claims? Whose fault is it when so many hands, from manufacturing to administration, have had to care for this package?
• Replacement: Shipments can be mis-delivered, stolen, or left unattended too long until you could get home and store them as indicated. Are you responsible for obtaining a replacement, and in time?
• Costs: even if you have met your yearly share of cost on the "medical" side, you may have to pay a separate out of pocket for "pharmacy" items.
D. Some Tips
• Shift to White-bagging: Can shipments be sent directly to the provider instead of your home, especially if you cannot receive the shipment or properly store it ? Threatening to hold your insurance liable for any adverse reaction may help.
• Appeal: If your physician must use his/her own supply, and the insurance refuses, an appeal can be filed explaining any risk of using a brown or white-bag drug (i.e you cannot store it safely, access to your PO Box is limited, you are in a hospital or away from home, the office is closed on the afternoon of delivery, your next treatment date must be pushed up...)
• Go Cash: B12 or iron, for example, costs a few dollars. Offering to pay the office directly for the drug will save time and efforts, and should be accepted by the grateful staff. They can still bill the administration fees to your insurance.
• Do it at home: to avoid transport to the office or infusion center, arranging the administration of your infusion or injection at your home through a home health agency may be a worthwhile alternative. Many home health agencies have their own pharmacies and would not require white-bagging at all.
In conclusion:
Be pro-active when your doctor prescribes an infusion or injection. Call your insurance to find out every detail, and your estimated or final cost.
Talk to the staff about any authorization requirement, and whether brown or white bagging set-ups will even be accepted. Many offices may not, citing legal liability and malpractice insurance constraints.
Don't take your insurance or PBM' s decision or policy as Final Truth. Filing appeals and access to safe, dependable and prescribed drugs are your rights, both as a Patient and a member of your plan.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
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@martine brousse 2025 @ the medical bill whisperer 2025â„¢