Entries by Eric Hartkopf, PharmD

Medi-Span® Generic Product Identifier

Health Information Technology vendors in the pharmacy industry utilize large drug compendia databases to manage electronic drug files so that electronic transactions are all “speaking the same language”.

Audit Issue: Patient or Prescriber Denials of Prescriptions

PAAS National® analysts have seen numerous PBM audit results where pharmacies had recoupments related to patient or prescriber denials of medications. Pharmacies are able to appeal by obtaining signed statements to overturn the denials.

Caremark Complex Compounds

PAAS National® analysts have recently worked with multiple pharmacies that received Compound Contract Violation notices from Caremark stating that the pharmacy must cease and desist submitting claims for “complex compounds” and reverse claims provided on an attached list.

Cash Copay Collection

Numerous PBMs are conducting audits and asking for proof of copay collection.

Bill it Right: AndroGel® Pump 88 g vs 75 g

Pharmacies have recently reported receiving telephone calls from Caremark’s audit department regarding claims for AndroGel® (testosterone) pump (and generics) related to incorrect package size billed.

Accepting Gifts Can Be an FWA Violation

The U.S. Department of Justice issued a press release on September 30, 2021, outlining that a former public official accepted “gratuities” (aka gifts or kickbacks) in exchange for referring business to a specific outside vendor.

Billing Insulin & Related Supplies – Medicare Part B vs Part D

PAAS National® analysts frequently field questions about billing insulin and related supplies – this can be particularly confusing when the patient has Medicare coverage. Coverage of insulin and related supplies may depend on both the type of Medicare benefit and how the item is being used. Specifically, insulin vials and alcohol swabs could be covered under either Medicare Part B or Part D!

COVID-19 Vaccine Billing Guidance

The coverage for COVID-19 vaccine may be under the pharmacy benefit (via NCPDP standard) or the medical benefit (via CPT codes). Here is a summary of billing information known to PAAS National® as of December 23, 2020.