Wisconsin Pharmacies Charged with Overbilling State’s High-Risk Program

Wisconsin is asking pharmacies that participated in its Health Insurance Risk Sharing Plan for high-risk patients to repay a total of $3.7 million that a recent audit asserts the pharmacies overcharged the state during the last two fiscal years, the Milwaukee Journal Sentinel reports. HIRSP, which is sponsored by the state DHFS, provides insurance for people who cannot purchase traditional coverage because of serious medical conditions. According to a report from the Legislative Audit Bureau, the state "paid in excess of allowed rates" on 75% of claims the pharmacies filed. The report added that the Department of Health and Family Services had "insufficient controls" to ensure that it is "paid at the allowable rates." HIRSP Director Margaret Kristan said that while pharmacies are supposed to bill the program "based on ... allowed amounts," they "were billing at their usual and customary amounts -- in other words, overcharging." Kristan said she informed the pharmacies that, for HIRSP beneficiaries, they were not allowed to bill the state more than they bill for prescriptions for Medicaid beneficiaries.

'Arcane' and 'Confusing' System
But Christopher Decker, executive vice president of the Pharmacy Society of Wisconsin, said that the program's "confusing billing system ... keeps pharmacists in the dark" about what they can charge HIRSP beneficiaries. Walgreen Co. withdrew its 137 pharmacies from the program last week, citing the program's "arcane billing system," the Journal Sentinel reports. In a letter to the state, Walgreen said it was ending its participation in HIRSP because the billing system prevented the company from "accurately pricing prescriptions for HIRSP beneficiaries consistent with their benefits under the plan." Walgreen denied any overbilling. While other pharmacies are not withdrawing from the program, they are "concerned about the administrative complexities -- in other words, the plain mess of things," Decker said. He added, "The pharmacies want to participate in HIRSP. Our society is working to see if some kind of arrangement can be made for a more efficient claims program." Decker said that pharmacies would "resist state efforts to make them pay back" any overbilling. Diane De La Santos, spokesperson for Aurora Pharmacies Inc., said that HIRSP should have its claims information online to allow "pharmacists to ... know the copays and deductibles, so they know they are billing appropriately." Kristan said that she expects to have patient billing information online by this summer and has begun price controls to prevent future overbilling (Manning, Milwaukee Journal Sentinel, 2/4).