Best Practices for Billing Vaginal Creams to Avoid Recoupment
PAAS National® analysts frequently receive questions regarding the proper billing of creams and ointments, an easy audit target for PBMs.
Entries by Jennifer Ottman, CPhT
Migraine Medications Continue to Cause Headaches
As PBMs continue to monitor claims for migraine medications, PAAS National® continues to receive questions about billing and the audit risks associated with these claims.
Standard Written Order and Medicare Part B Audit Risks – New Guidance
If you are a Medicare Part B provider, then you know how cumbersome a Medicare Part B audit can be. For most Medicare Part B audits, a pharmacy would be required to provide a valid Standard Written Order (SWO), medical records to support the diagnosis and continued need of the item, proof of delivery, and proof of refill request if mailing or delivering supplies.
Seeing Too Many or Repeated Prescription Validation Requests – Take Action!
See the PAAS tips for best practices on how to track and manage duplicate or high numbers of prescription validation requests.
PBM Communications to Network Pharmacies Can Help Prevent an Audit!
PAAS National® knows community pharmacies are busier than ever, making it difficult to keep up with all the PBM communications.
Audit Target – Pre-Filled Injectable Pens and Syringes
Pre-filled injectable medication such as insulin, Invega®, Humira®, Enbrel® and Ozempic® remain a big target for audit risk due to their high cost and potential billing pitfalls.
Post-PHE Claim Submission Requirements for Continuous Glucose Monitors
Now that the PHE has ended and CMS is enforcing clinical indications for CGMs and supplies, pharmacies are left wondering what will happen with continued or refilled claims for CGM related supply items initially provided during the PHE under the waiver/non-enforcement.
Continuous Glucose Monitors and Potential Audit Risk with PHE Ending
As the COVID-19 Public Health Emergency (PHE) declaration comes to an end on May 11, 2023, preparing for some changes to current flexibilities, actions and waivers that have been in place since COVID-19 began is crucial.
Avoiding Humana Audits for Deceased Patients
Humana has recently sent out another round of audits to pharmacies with the subject line: Review of claim(s) billed after member’s deceased date.
A Documentation Checklist for Continuous Glucose Monitor Claims
For any item to be covered by Medicare B, there must be clinical documentation to support the covered diagnosis, prove it is reasonable and necessary for treatment and meet all other Medicare requirements.
