Right now the two books on our night stand were both written by finance guru and born-again Christian Dave Ramsey. Tom is reading The Total Money Makeover and I am engrossed in Financial Peace. Dave also created a money management series called Financial Peace University-- I like to think that my thrifty husband is the Dean. As for me, I will probably be lucky to earn a "C" since I am, without apology, the "Queen of the Credit Card." And what does this have today with today's commentary?
The facts:Claimant is getting her drugs from Dr. Ganesh Balu, a local pain management doc. The amount he charges is admittedly compatible with the Delaware Fee Schedule for these medications. The employer requests that claimant use Express Scripts to save them (or their carrier) money. With Express Scripts the claimant can utilize any one of a large number of pharmacies to fill her medications or have them mailed to her home-- the same brand name medications and dosage as she is currently obtaining. It just happens that the charge is less than that of Dr. Balu.
The outcome and how we get there?* A pharmacy is not a medical provider pursuant to 19 Del. Code Section 2323.* The Delaware Treatment Guidelines have separate definitions for "provider" and "pharmacy".* 19 Del. Code Section 2322 requires the employer to provide medications as necessary, which is what it is doing with Express Scripts.* Requiring the claimant to utilize Express Scripts is not the same as directing her medical care.
Another "Motion Day" ruling. Patricia Boone v. Syab Services, IAB # 1198151 (10/5/11) (ORDER) And Joe Klusman is my new hero. Because it's all about saving money where we can and when we can-- even if you are an insurance company.
Wishing you all a little Financial Peace!
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