Continuous Glucose Monitor (CGM) Billing and Supply Allowance
CMS has issued an update on the Glucose Monitor – Policy Article effective as of January 1, 2024.
Entries by Jennifer Ottman, CPhT
DMEPOS Updated Refill Request and Affirmative Response Requirements
Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims. If you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems during an audit.
2024 Update: CMS Mandatory E-Prescribing Requirements for Controlled Substances – Final Rule
The SUPPORT Act was created to address the opioid crisis in our nation. Section 2003 states that all Schedule II-V controlled substance prescriptions under Medicare Part D and Medicare Advantage plans (MA-PD) must be transmitted electronically.
PBM Prescription Validation Requests Rose 123% in 2023 – What You Need to Know
PAAS National® saw the number of validation requests/concurrent claim reviews more than double in 2023!
Unveiling a Multi-Million Dollar Fraud and Kickback Scheme
According to an August 18, 2023 press release from the Department of Justice (DOJ), a pharmacy operations manager and some co-conspirators have pled guilty to committing healthcare fraud and to paying illegal kickbacks for Medicare and Medicaid claims that were never dispensed to patients.
Insufficient/Missing Clinical Notes Yield Audit Recoupments
PAAS National® analysts are seeing more prescriptions flagged for recoupment when insufficient or missing information is not verified with a valid clinical note.
Biosimilar Advancements: Understanding the Latest Updates on Humira® with Cyltezo® and Abrilada™
At the time our April 2023 Newsline article Biosimilar Adoption for Humira® in 2023 was published, eight FDA biosimilars for Humira had been approved, and five more were pending approval.
$32 Million Kickback Scheme Involving Medicare and TRICARE
According to an August 18, 2023 press release from the U.S. Attorney’s Office, District of New Jersey, a former president of a pharmacy business pleaded guilty to a scheme that violated the Federal Anti-Kickback statute.
Breyna™ – The First FDA Approved Symbicort® Generic With a 0.1 Gram Problem
Breyna™, like Symbicort® is approved as a maintenance therapy for people with COPD and for asthma patients ages 6 and older.
PAAS Defends Community Pharmacies by Engaging DME Medicare Administrative Contractor CGS
In our August Newsline Standard Written Order and Medicare Part B Audit Risks – New Guidance, we shared a few examples some of our members are having on audit results regarding their Standard Written Order (SWO). Beyond writing the Newsline, PAAS National® also reached out and engaged nurse medical reviewers with CGS about our concerns on the three topics below.
