A recent OIG report found that Medicare may be overpaying suppliers for Continuous Glucose Monitors (CGMs) and supplies relative to other payers. The report highlighted the following: As a result of the findings, OIG has recommended that CMS reduce payments for CGMs and supplies and address improper use of billing codes to reduce overpayments. CMS […]
PAAS National®® analysts have identified a recent trend of audit enforcement related to days’ supply for eye drops, with a particular focus from Prime Therapeutics. Most PBMs provide a “drops per mL” estimate in their provider manual, but they often provide a qualifier that pharmacies should use the PBM estimate “unless otherwise indicated by the […]
The Office of Inspector General (OIG) recently released a report outlining $22.7 million in improper payments from 2018-2024 for DMEPOS provided during inpatient stays. This was a follow up to a previous report issued in 2018 that found over $34 million in improper payments from 2015-2017. The CMS identified system edits that were not working […]
Starting in 2026, Medicare has negotiated the price of 10 brand drugs under the Medicare Drug Price Negotiation Program as part of the Inflation Reduction Act of 2022. The negotiations between CMS and drug manufacturers have resulted in Maximum Fair Prices (MFPs). To implement this program, CMS has created the Medicare Transaction Facilitator (MTF) which […]
Most community pharmacies don’t compound with hazardous drugs, but that doesn’t mean you’re off the hook when it comes to USP 800 compliance. This standard, USP General Chapter <800> Hazardous Drugs: Handling in Healthcare Settings, applies to anyone who receives, stores, or dispenses hazardous drugs (HDs). And yes, that includes community pharmacies. What Makes a […]
Each PBM has their own unique set of “rules” for network pharmacies to follow, and they publish these rules in their Provider Manual. Pharmacies should be aware these Provider Manuals are an extension of the Provider Agreement and contractually obligate pharmacies to adhere to these requirements. To make matters worse, PBMs update these manuals at […]
Caremark frequently issues desk audits, labeled as LTC Override Code Audits, to validate certain override codes that allow LTC pharmacies to process claims without having to call the helpdesk (generally due to early refill rejections). Submission Clarification Codes (SCC) may be input by pharmacies into NCPDP field 420-DK to identify unique dispensing situations such as […]
Each fiscal year, the Department of Health and Human Services (HHS) publishes improper payment rates for Medicare FFS Part A, Part B, and DMEPOS claims submitted between July 1 and June 30. These error rates are determined through Comprehensive Error Rate Testing (CERT) audits of a stratified, randomized sample of claims across various provider types […]
PAAS National®® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites […]
