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A series of emails we received from a subsidiary of United Healthcare raises more serious questions about the countrys largest health carrier. Our investigation last week showed United says its charging customers a copay for some drugs. But in actuality, that copay is a you-pay - United charges more than the cost of the drug.
The absurdity is beyond belief, says a pharmacist who spoke to us on condition of anonymity.
This pharmacist is among the sources providing FOX 8 with example after example of copays that are higher than the actual cost of the drug. Pharmacists call this a clawback - healthcare providers clawing back money from pharmacies and customers.
In a statement to FOX 8 News, United Healthcare through its subsidiary, Optum - admitted to the practice, writing:
OptumRxs Pharmacy Reimbursement Overpayment program helps ensure the millions of people we serve have affordable access to the drugs they need.
OptumRx causes the overpayment to happen and they get the money, our source tells us.
We emailed Optum back and said we Googled the program name but and didnt see any documentation or reference to it on the Internet.
An Optum spokesperson responded, Im not sure theres an official name.
Remember: They referenced the program in the statement and even capitalized the first letter in each word, OptumRxs Pharmacy Reimbursement Overpayment program - usually an indication its a proper noun, a real thing.
In that statement, Optum told us the Pharmacy Reimbursement Overpayment program recoups overpayments that pharmacies receive for prescription drugs:
Those recouped overpayments arereturned to the health plan to reduce overall health plan costs.
But our local pharmacist says the statement is misleading. He tells us Optum sets the cost of the drug and the amount of payment.
We collect that overpayment right there because they told us to take it, he says. But we have to send it right back to them.
United Healthcare, through its pharmacy benefit manager Optum, essentially is charging people a premium on drugs - people are unknowingly paying more for a drug than its actually worth.
In our email exchange, Optum stressed:
A consumer doesnt pay any more with this program than they would without it.
But documents and information provided by pharmacists show thats simply not true.
A case in point: Optum required a pharmacist to charge someone a $50 copay for the acne and birth control pill Sprintec. Optum noted the actual cost of the pill, $11.65, and made the pharmacy send the difference back to them, Optum or United. According to the online pharmacy search website LowestMed.com, the same consumer could have bought this drug without using insurance, at both independent and chain pharmacies in the area, for $13.66. They could have saved about $36.
Still, in that email exchange, Optum reiterated:
To be clear: this program ensures the customer pays the lowest amount possible within their plan.
That didnt appear to happen in another example, either. Optum had a pharmacist collect a $15 copay for an anxiety drug. But if someone had come into our sources pharmacy and paid for that drug without insurance, the pharmacist says, We would have charged $9.64, just cash off the streethellip; They would have saved, wellhellip; $5.36.
United and Optum label this a copay, right on the paperwork. But the company pays nothing toward the cost of these drugs.
Its not a copay, the source insists. Copay, by definition, means we pay some, you pay some. [But] this is strictly lsquo;I am paying the pharmacy for the meds and Im giving you money for the privilege of saying I have insurance.
Optum sent us one more email, noting yet again:
There is no difference in cost to consumers as a result of this pharmacy benefit program.
Yet pharmacists gave us document after document that show United/Optum collecting more money in a copay than the drug is actually worth. Thats customer after customer after customer who could have paid cash, paid without insurance, and saved money. You
Like many pharmacists, our source has a contract with Optum. When we ask him what might happen If Optum identified him as a source for our investigation he told us, They would come after me. They would want to kick me out of network because were not supposed to disclose anything.
The source says United and Optum dont want pharmacists telling the truth because people would be outraged if they knew that they were actually paying an extra premium, every time they got a prescription filled.
We requested an on-camera interview with Optum; they have yet to agree to that. We also told them we found many examples of medication that would have been cheaper for customers to buy off insurance, and asked, How is there no difference in cost to the consumer?
We wanted to know why Optum isnt telling customers, in some cases, that there is no copay - only one person is paying. We also wanted documentation on this overpayment program, and documents that inform customers they may be overpaying for drugs. And we wanted proof that these overpayments actually reduced overall health plan costs - some other companies dont have such a program, after all, and dont overcharge for drugs.
Optum never responded.
I can tell you the reason why they didnt want to respond, our pharmacist says, because if they respond, theyre expected to respond truthfully. And thats total nonsense.
We did get one more email from Optum last week, clarifying their statement. After we peppered them with questions, the program used as a proper noun changed - capitalized letters changed to lowercase - and Optum eliminated the word overpayment:
OptumRxs pharmacy reimbursement program helps ensure the millions of people we serve have affordable access to the drugs they need by ensuring they pay the lowest price available to them for prescription drugs.
We gave United and Optum a deadline of close of business Friday to respond to our questions.We never heard back. A spokesperson did email us at 4:30 Monday; he said, at this time, the company would not provide any on-camera interviews.He also did not answer any of our questions, but did say he may be able to provide an expert to speak on background later this week.
Copyright 2016WVUE. All rights reserved.
In late Januarymembers of the Federal Bureau of Investigation, Mississippi Bureau of Narcotics, Internal Revenue Service and multiple other state agencies raided four businesses related to pharmacies in theHub City, and seized millions in assets.
Those raids covered multiple states, including Utah,Alabama and Florida as well as other locationsacross Mississippi.
Roughly five months later, federal court documents have been unsealed, shedding light on aspects of the raids. The documentsrevealedat least $11 million in property.
Below are the claimants listed in the case summary of the forfeiture filings involved in the case:
Court documents showed that the case involves criminal fraud against various programs funded by the US Government. ThisincludesTRICARE,Department of Labor Office of Workers Compensation, and the laundering of the criminal proceeds.
According to thedocuments, some of the subjects of this investigation own and operate numerous pharmacies that market and prepare compound medications. As general practice, compounding pharmacies create custommedications based upon a specific prescription written by a doctor.
The document explains:
Many of the subjects have engaged in price rolling, which isalso known as price testing. This type of fraud occurs when a pharmacy employee suits a claim to an insurance provider to test the amount of reimbursement for a specific prescription. This claim is often retracted or canceled,and a new claim is submitted using a different compounding formulation to determine if the new claim is reimbursed at a higher rate.
Pharmacies involved are known to automatically refill prescription in spite of doctors orders and/or if thepatient wishes not to refill the prescriptions. In some instances patients were offered payments, told to destroy medications, to keep them from canceling the automatic refills, or from returning the medications.
The document continues:
If a patient returns the medication, the pharmacy is obligated to reverse its claim to the insurance program.Many of the pharmacies tell their patients that they do not have to pay co-pays or they make no effort to collect the co-pay.
According to one informant, one of the pharmacies paid itsemployees to purchase Green Dot cards that were then used to pay patient co-pays.
Alternatively, the pharmacy may offer a co-pay rebate or cousin program. These programs often make it appear that a co-pay has been paid, but the money is often funneled through intermediaries from the pharmacy.
Court documents showthat many patients have received prescription medications without having ever seen,or even knowingthe doctor that prescribed the medications.
The subject pharmacies are believed to bill for ingredients that are not contained in the actual compound medications in order to receive a higher reimbursement from the insurance programs.
According to the document,
Many of the pharmacies are known to use affiliates or shell companies to hide their involvement from certain insurance programs.
Through marketing companies, which are under the control or direction of the co-conspirators, kickbacks, or incentives were paid to healthcare providers to prescribe compounding medications that were filled by subject pharmacies.
The investigation has uncovered evidence that proceeds fromthe alleged health care fraud and money laundering were used directly, indirectly, to purchase the defendant Real Properties.
Real Properties listedin case filings:
M. Ray (Hoppy) Cole, Chief Executive Officer and President of The First, A National Banking Association andone ofthe claimants listed in the case summary of the forfeiture filings involved in the case, released a statement Tuesday,in regards to this matter.
The First, A National Banking Association, was listed as a Claimant because the bank, as a secured creditor, has a deed of trust lien interest in two of the properties against which the US government has taken action. The bank simply asserted its lien interest in those two properties through the claim process outlined for Civil Forfeiture In Rem proceedings.The First is not involved in any way with the alleged pharmaceutical scheme or the target of any investigation related thereto. Unfortunately, the media reports failed to make any distinction in their reporting as to Claimants who are owners of the property seized and those that are secured creditors, such as The First.
Copyright WDAM 2016. All rights reserved.
A local tow truck driver said he refused to tow a womans car after he saw Bernie Sanders stickers on the vehicle.
Kenneth Shupesaid he was called to pick up a woman stranded on I-26 in Asheville on Monday.
When he saw a bunch of Bernie Sanders stuff he said he told the woman, very politely, that he couldt tow her car because she was obviously a socialist and advised her to call the government for a tow.
Every business dealing in recent history with a socialist minded person I have not gotten paid, Shupe said. Every time I deal with these people I get Bernedwith an enot a u.
Shupe, who runs Shupee Max Towing in Travelers Rest, said he is a conservative Christian who supports Republican presidential candidate Donald Trump.
Shupe said he has drawn a line in the sand not to do business with Bernie Sanders supporters.
Sanders is running for president in 2016 on the Democratic ticket.
I respect their beliefs, and I hope they respect my views, Shupe said Wednesday.
The womans mother KelleMcWade posted an angry message on Facebook after the incident, calling Shupe a bigot.
Trumps motto is Make America Great Again, McWade said. And this kind of divisive behavior is not going to make America great again.
Below is KelleMcWades public post:
Heads up, friends.... Cass had a wreck in Asheville yesterday. She is fine, but the car was not driveable. We called our mechanic who was tied up in Easley at the time, so he sent ShupeeMax Towing to get her. Kenneth Shupee drove from Travelers Rest to Asheville, hooked up her car, and when he went around to the back, he came back and told her that he wouldnt tow her because she had a Bernie sticker on the back of the car. HE LEFT HER ON THE SIDE OF THE INTERSTATE IN NC, and DROVE AWAY. Spread this bigots story far amp; wide. Btw, Im guessing hes a Trump supporter. The only difference is that the Don would have taken the money, because he at least realizes that liberals money spends just the same as anyone elses. Dumb (expletive) cost himself money driving all the way to Asheville amp; back for nothing. (Expletive).
A major point of contention between Shupe and McWade is her daughters health. McWade said her daughter suffers from multiple health issues andclaims Cassyhad a handicap placard displayed inside her vehicle at the time of the towing debacle, but Shupe maintains he never saw it and did not know the girl was disabled.
Cassy McWade said she suffers from Psoriatic Arthritis, Fibromyalgia, Chronic Fatigue Syndrome, and early stage Crohns disease.
Sitting on the side of the road for hours without a restroom was terrifying, and I take 18 prescriptions daily, Cassy said.
Kelle McWade took to Facebook again on Thursday and once again called Shupe a liar.
So, apparently Mr. Shupe has made a lot of claims that are outright lies. Id like to clarify a few points, in case any of you have any questions or are speaking to someone who brings any of these points up:
No one EVER asked him to tow her for free. My mechanic sent him ONLY because he couldnt get there in a reasonable period of time and he was worried about her beingleft there too long BECAUSE she is disabled. The car was to be towed to my mechanic, who agreed to cover the bill for me. Weve been doing business with him for 10 years. If I didnt pay my bills, do you think hed have done that or been willing to pay the tow bill for me until I could get to him to pay him back? Anyway, Ive already paid him back..the SAME DAY. He still has my daughters car to fix it. Make no mistake that Ken Shupe is a bald faced liar. He also lied about not knowing that she was disabled. Her placard was hanging in the car the whole time, and our mechanic told him that was the whole reason he asked him to go in the first place..BEFORE he ever went. He claimed on HuffPost that she was safe. He said her car was locked, the windows up and the A/C on...it was very hot that day. That was impossible, considering wiring and hoses were cut in the wreck and the car had absolutely NO power at all. We couldnt even put the windows back up when it got to the tow yard to protect it from the rain, because it has no power. Dont believe everything you read. I can substantiate EVERYTHING I and my daughter have claimed. I guarantee you that Ken Shupe cannot.
To my knowledge, tow truck operators have a lien on vehicles that they tow, and have the right to hold the vehicle as collateral...and charge storage fees... until its paid. So, how exactly has he been allegedly burned by Bernie supporters in the past...and how does he know that they were Bernie supporters? You know hes lying when his lips are moving.....
?For the record, I work a job and a half, own my house and all three of my cars free and clear...but Im a deadbeat, right??? I pay cash for everything. If I cant afford it, I apparently dont need it.
Greenville Attorney Steve Sumner weighed in on the situation saying,We may not like it and we may not agree with it but I dont believe any laws were broken.
Sumner said unlike race, sexuality, and religion, political affiliation is not a protected class.
As long as there is no contract between the driver and the tow truck company then there is no legal obligation for the tow truck company to pick her up, Sumner said.
Shupees Used Cars LLCis in no way connected to Shupee Max Towing, and has nothing to do with the incident. The owner of that business said shehas been flooded with harassing calls from people who are mistaking her business with Kenneth Shupes. She said she has even received bomb threats and death threats, all due to a misunderstanding.
MORE:Business owner caught in political crossfire
Copyright 2016 FOX Carolina (Meredith Corporation). All rights reserved.