How to: File a complaint for #InsuranceReform
Our state and federal legislators, as well as other governmental bodies, rely heavily on stories from patients and providers to (1) identify issues affecting our nation’s healthcare system and (2) find meaningful solutions to those issues, many of which will or have already required legislative reform. This is especially true in our industry, where little to a complete lack of transparency, among other systemic issues, has allowed Pharmacy Benefit Manager (PBM) abuse to grow out of control while few people remain aware of it. Whether you’re a patient or pharmacy provider, below you’ll find helpful information about how and to whom you should complain about problems you face accessing/providing pharmacy care or filling your/patients’ prescriptions.
A few tips & tricks
When in doubt, submit a complaint! Regulatory bodies are legally required to look into each and every complaint they receive from concerns citizens or consumers—it’s their job. Additionally, just because a complaint isn’t “valid” in the sense that it, technically, “broke the rules” as they currently stand doesn’t mean it isn’t valuable (especially because rules, of course, aren’t always fair, equitable, etc.). Every single story that these agencies hear about is an opportunity for the word to spread—our leaders can’t change things they don’t know about or don’t understand, and that knowing and understanding often comes from everyday people like you and us. So, if you’re doubtful of whether your complaint is warranted, submit one anyway—it can’t hurt, but it might help.
Before submitting any complaint, make sure to save a copy of it along with any supporting documents by doing one of the following. This way, you’ll have a record of what you submitted if the applicable entity contacts you for more information.
Utilize the online portal of whatever entity you submitted a complaint to: This isn’t offered by every governmental or other regulatory body that accepts complaints and usually requires setting up an account, but offers more features than submitting a complaint manually via email or verbally via phone, including saving past submissions and tracking the status of a complaint as it’s investigated.
Take a screenshot on your device: Hold the control (Windows) / ⌘ (Mac) and P keys on your keyboard at the same time to print a screenshot of your filled out complaint and attach it to whatever file(s) you’re planning to upload to support your complaint.
Copy and paste the details of your complaint (i.e., your story) somewhere safe, such as in your phone’s note-taking app or on another other personal device.
For patients
If your insurance company and/or your plan’s Pharmacy Benefit Manager (PBM) have ever impeded your pharmacy care*, please file a complaint with either the Minnesota Department of Commerce (MN DOC) or Centers for Medicare and Medicaid Services (CMS). Their staff read each and every complaint, and we know firsthand from fellow independent pharmacists across our state that they are listening, and learning, and becoming more and more concerned about the misconduct of health insurance companies and PBMs. They’ve been receiving Pharmacists’ and pharmacies’ complaints for years; now it’s time they hear the stories of patients like YOU. See below for instructions on how to submit a complaint to each of these entities.
*Examples of this include:
Being forced by your insurance company to move your prescriptions to a mail order service or pay 100% of your prescription costs at a local pharmacy (a classic example of “patient steering”)
Being forced to pay a higher copay for a brand-name medication when there are far more cost-effective generic alternatives
An insurance company you are no longer covered by allowing a prescription claim to go through on your behalf (i.e., being wrongly represented as covered by an insurance entity you are no longer a member with)
Click here to view Minnesota Statute 62W, otherwise known as the “Minnesota Pharmacy Benefit Manager Licensure and Regulation Act,” which legally defines patients’ rights in the state of Minnesota in regard to PBM conduct and their obligation to covered patients and the pharmacies serving them.
Submitting a complaint to MN DOC
If you have commercial insurance (e.g., through your employer or school), click here to be led to MN DOC’s “File a Complaint” page. Submitting complaints through their online portal is the most efficient way to do so and allows you to see the status of your complaint, communicate with the investigator, and add supporting documents through the investigation, but does require an email address. You can also submit your complaint via email or phone.
After submitting your complaint, you should receive an email from either Victoria or Norman from MN DOC confirming they received your complaint and that it’s in progress. If you don’t hear anything right away, don’t be discouraged! For example, a fellow independent pharmacy owner thought they were ignoring one of their complaints for two years, but they later found out that MN DOC didn’t want to close the complaint because it became part of a lawsuit the AG brought against CVS. Since it was an ongoing investigation, they could not tell this Pharmacist anything at the time.
Submitting a complain to CMS
If you have health insurance through Medicare, click here to be led to CMS’s online complaint form. You’ll need information from your Medicare card in order to submit your complaint. If your complaint is regarding an urgent issue that requires a resolution within 10 days, Medicare requests that you give them a call at 1 (800) MEDICARE.
Other ways to share your story
Contribute to the New York Times’ PBM investigation | Complete their brief online form that asks questions about your experience working with any of the “big 3” PBMs that currently dominate the industry—CVS Caremark, Express Scripts, and OptumRx—and your prescription costs
Submit a complaint to the Federal Trade Commission (FTC), the independent agency of the United States government whose principal mission is the enforcement of civil antitrust law and the promotion of consumer protection. Link(s) to their ongoing investigation(s) are listed below:
Solicitation for Public Comment to Understand Lack of Competition and Contracting Practices that May be Contributing to Drug Shortages | Share how you have been or are currently being impacted by shortages of the drug(s) you take (e.g., stimulants, injectables, and antibiotics; a dynamic list of current drug shortages can be found here)
Questions or need help submitting a complaint? Email hildie@stpaulcornerdrug.com.
For healthcare providers
While regulatory bodies often prioritize hearing directly from or about patients’ challenges with our healthcare system, our stories are important, too—especially when it comes to those of us operating and working in independent pharmacies, which are currently facing financial turmoil at the hands of PBMs and their abusive conduct. Below is a collection of complaint opportunities we’ve discovered on our own or through interactions with fellow healthcare providers. While most are focused on pharmacists and other pharmacy workers, some are applicable to other healthcare providers as well.
Submitting a complaint to MN DOC
Click here to be led to MN DOC’s “File a Complaint” page. Like patients themselves, we can submit complaints on behalf of the individuals we care for when we believe their rights have been violated by their insurance company or their plan’s PBM. Additionally, MN DOC fields complaints regarding other commerce-related issues, including PBM abuse that affects pharmacies directly. Of note, MN DOC’s scope of complaints that they are legally able to investigate appears limited and inconsistent (or, in some cases, still being debated), but they’ll always let you know if your complaint is outside of their jurisdiction. Per guidance from fellow indie pharmacists with extensive experience submitting MN DOC complaints, key topics that they do or might have jurisdiction over include:
Patient steering, manifestations of which include:
Claim rejections stating that refills aren’t covered and must be filled via mail order (yes, patients can technically opt out, but in reality it often requires an unreasonable amount of effort/understanding on their part)
Claim rejections stating that specialty medications must be filled by the PBM’s own specialty pharmacy.
Phone calls from the PBM/insurance plan to the patient to "go over their medications" and suddenly the patient is notified by the PBM’s mail order pharmacy that their “order is ready to ship.
Patients being given flex cards to purchase OTC products that are only usable at the big box stores
Inappropriate transfer requests (these are referred to MN Board of Pharmacy, but DOC wants to hear about these cases as well so that they know what is going on). Per feedback from other indie pharmacists, Amazon and Smith have been the worst offenders of these inappropriate requests.
Clawbacks/DIR fees. Per feedback from other indie pharmacists, it’s best to leave specific claims you are submitting a complaint about processed, as reversing these claims leads PBMs to say that there are “no such claims in our system.” Per recent developments, manifestations of this issue might also include:
GoodRx and other discount cards being embedded in claims processing | MN DOC does not yet know if they have jurisdiction, but are actively looking into this newfound issue and working with the MN Attorney General’s office (per the assumption that, if there is money being applied to a patient’s deductible, it is no longer a discount card and, instead, “actual” insurance that MN DOC might have jurisdiction over).
Medicare Part D claims | MN DOC’s response has traditionally been that CMS has jurisdiction over these complaints, but they are now actively reviewing the language in 62W and say they may not have to carve out these claims.
Performance Network clawbacks | Traditionally, these claims have been considered exempt from MN DOC’s jurisdiction through the rules making process, but they are revisiting this again because a real-time clawback is not retrospective, as the rules were originally written to exclude.
MAC/pricing appeals when PBMs use obsolete or unavailable NDC numbers to set the MAC price. This happens less commonly these days due to changes in PBM practices, but is still relevant in some scenarios. Examples include:
Discovering that pricing on a prescription turns out differently when the claim is reversed and rebilled after sitting in the pharmacy’s will call bin for 10+ days
When the patient’s insurance plan forces them to use the brand-name version of a drug, but the brand-name version isn’t available and the generic version isn’t covered at the brand price. Pharmacies we know who have faced this situation have completed the PA process then reported the PBM’s contradictory response, which has traditionally been that the pharmacy “can dispense the brand and will be reimbursed according to their contracts.”
Audits. What was acceptable as evidence to fight audits has changed in 2024, so, if your pharmacy is being audited and losing, this is something to complain about, especially if updates your contracts didn’t include changes to the provider manual in the audit section. Complaints regarding audits that have already been submitted to MN DOC are actively pending, but the assumption is that the current language in 62W should protect pharmacies from this issue.
Of note, MN DOC does NOT have jurisdiction over complaints related to MA or MCO claims for Medicaid patients (which should be referred to MDH) or Medicare Part D claims (which should be referred to CMS).
After submitting your complaint, you should receive an email from either Victoria or Norman from MN DOC confirming they received your complaint and that it’s in progress. If you don’t hear anything right away, don’t be discouraged! For example, a fellow independent pharmacy owner thought they were ignoring one of their complaints for two years, but they later found out that MN DOC didn’t want to close the complaint because it became part of a lawsuit the AG brought against CVS. Since it was an ongoing investigation, they could not tell this Pharmacist anything at the time.
Submitting a complaint to MN Board of Pharmacy (BOP)
Click here to be led to the MN Board of Pharmacy’s “Complaints” page. The board is required to investigate all jurisdictional complaints against the individuals and businesses that it regulates and violations of the Pharmacy Practice Act.
Submitting a complaint to MN Department of Health (MDH)
Unfortunately, there is currently no avenue to submit complaints about MA or MCO prescription claims; as of now, MDH only accepts complaints against a specific facility or professional, despite the fact that these claims are within their jurisdiction. We are actively investigating this issue and awaiting word from MDH about how healthcare providers can submit complaints regarding these kinds of claims.
Submitting a complain to CMS
Click here to be led to CMS’s online complaint form in order to help one of your patients submit a complaint. They’ll need information from their Medicare card in order to submit their complaint. If their complaint is regarding an urgent issue that requires a resolution within 10 days, Medicare requests that the patient give them a call at 1 (800) MEDICARE.
If you have a complaint specifically regarding Medicare Part D plans, email partd_monitoring@cms.hhs.gov.
Submitting a complaint to the FTC
Links to ongoing FTC investigations can be found below. Please note that complaints to the FTC can be signed or submitted anonymously, if you’re concerned about retaliation, so there’s no reason not to share your story!
Solicitation for Public Comment to Understand Lack of Competition and Contracting Practices that May be Contributing to Drug Shortages | Share your thoughts on how drug wholesalers and shortages are affecting your business and/or the care you provide to patients (more specifically, “whether and to what extent lack of competition among GPOs and drug wholesalers impacts patients, hospitals, healthcare providers, pharmacies, generic manufacturers, and other suppliers”).