PBMs require pharmacies to not only collect patient copays, but also have documentation to prove it. It is common for PBMs to request proof of copay collection when performing audits. Copays are used by the insurers to help patients understand medication costs and to encourage less costly alternatives. Pharmacies that alter or waive copays set […]
Billing packaged products according to their proper size and unit of measure is crucial for pharmacies, as this common pitfall could result in hefty recoupments from PBMs. When it comes to billing insurance, a medication like Divigel® (estradiol) transdermal gel packets can be confusing for pharmacies, as different strengths use different billing units. Some are […]
Billing insurance isn’t always simple, whether it’s formulary issues, step therapy or plan limitations, it’s common for a pharmacy to receive a rejection when trying to bill a patient’s insurance. For patients with Medicaid as secondary coverage, can you simply send the rejected claim to Medicaid? Caution should be exercised.
As technology continues to reshape modern medicine, medical providers have embraced electronic prescribing to improve patient care. Unfortunately, as the healthcare landscape evolves, so do the tactics of bad actors seeking to exploit it. Bad actors can use stolen login credentials from prescribers to gain access to electronic health record systems and initiate thousands of […]
Glucagon emergency products are typically low audit risk – when billed correctly. Billing the wrong unit of measure, like “EA” instead of “mL”, is an easy target for auditors to flag. Below is a table to aid in billing the correct unit of measure.
When updating or changing pharmacy management software systems, pharmacies may be presented with different options to archive the files from the software they will no longer be using. While it may not seem worth the extra cost now, ensuring that you are able to retrieve appropriate data for old claims is crucial to avoiding costly […]
You’re preparing for an upcoming desk audit, and while pulling the hard copies for a PAAS National®® analyst to review, you notice a billing error. It’s a simple fix, like an incorrect days’ supply, so you try to reprocess the claim. However, now you’re hit with an unexpected rejection …
In December 2024, a Tennessee pharmacist was arrested and charged with nine counts of Health Care Fraud and six counts of Aggravated Identity Theft for operating a health care fraud scheme that resulted in over $6 million worth of false claims being submitted to several insurers. A federal indictment returned in late December revealed that […]
Good news! The Public Readiness and Emergency Act (PREP Act) did not expire at the end of this year, according to a declaration published on December 11, 2024, by the U.S. Health and Human Services (HHS). The declaration has extended the authority for pharmacists, pharmacy interns and pharmacy technicians to administer vaccines and test patients […]
Topical medications like creams and ointments are always a target for PBMs to audit, but lurking in those topicals is a bullseye that PBMs are always aiming for – vaginal creams. Estrace® and Premarin® are easy targets due to the variety of discrepancies that could be found when auditing. The most common error PAAS National®® […]
