Insurance Limits Quantity – Common Scenarios and Pitfalls
When processing prescriptions, insurance companies require pharmacies to bill an accurate days’ supply derived from mathematical calculations obtained from the directions.
Entries by Jenevra Azzopardi, CPhT
Quantity Changes Cause Audit Appeal Trouble
PAAS National® is seeing more discrepancies for “unauthorized” refills on audits and PBMs continue to make these discrepancies difficult to appeal.
Best Practices: Medication Delivery
With the Public Health Emergency (PHE) for COVID-19 ending May 11, 2023, a return to pre-pandemic requirements for proving patient receipt of medications is anticipated.
Audit Trap: OptumRx’s Provider Manual Requirements
PAAS National® is starting to see more recoupments from OptumRx for missing prescription information.
PHE for COVID-19 Ending May 11, 2023: Pharmacy and Audit Ramifications
On January 30, 2023, President Biden’s administration announced that both the national emergency and public health emergency (PHE) for COVID-19 would be ending on May 11, 2023. This will have far-reaching implications for everyone in healthcare, including pharmacy.
Audit Risk: Pre-Printed Prescription Forms
At a time when the workday seems to be growing ever more hectic, prescribers and pharmacies may find pre-printed prescription forms convenient; especially for medications which are frequently utilized by a prescriber for treatment. Many PBMs prohibit pre-printed prescription form use for various reasons.
Why Does Billing the Correct Origin Code Matter?
Pharmacies are required to enter an origin code on claims to indicate where the prescription came from or “originated.”
Valid Prescriber/Patient Relationships and Marketing Concerns
With the U.S. Department of Health and Human Services Office of Inspector General’s (OIG) recent focus on telemedicine fraud, pharmacies may be wondering what their obligations are when determining a prescription’s authenticity – especially when it comes to whether a valid prescriber/patient relationship exists.
The Ballad of Snowbirds and Audits
The winter months have many pharmacies mailing prescriptions to their snowbird patients who leave their northern nests for more hospitable climates.
What Do Bowel Preps, EpiPen®, and Migraine Medications Have in Common?
Prescriptions for medications whose dosing is standardized in the industry often come with directions that simply state, “Use as directed.”
