Over the past few years, the number of medications available and prescribed for migraine prevention and treatment has notably increased, which leads to additional audit risks. PBMs continue to monitor and audit migraine medications due to their high cost, often incalculable instructions and common billing errors. Our PAAS National®® analyst team wants to help you […]
Santyl® ointment is a high dollar topical medication with specific instructions for application which carries high audit risk and potential recoupment from your pocket. Pharmacies need to follow the guidance below to help reduce their audit risk.
CMS rolled out the Targeted Probe and Educate (TPE) program back in 2017. The goal of the TPE program is to help providers reduce the number of DMEPOS claim denials by using data analysis and providing one-on-one educational sessions to avoid common mistakes. DME Medicare Administrative Contractors (MACs) analyze data to identify providers who have […]
PAAS National®® analysts field many questions on Ozempic® relating to off-label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing. Section 2.2 of the manufacturer package insert (available on DailyMed) lists the recommended dosage schedule based on clinical trials and includes the following titration schedule: […]
Per NCPDP’s Telecommunication Version D and Above: Questions, Answers and Editorial Updates, “the Prescription Origin Code (419-DJ) contains the value that represents the method in which the pharmacy originally received the prescription from the prescriber.” Any subsequent changes or modifications to the original prescription do not change the origin code even when clarifications of that […]
PAAS National®® continues to see a large number of EPIPEN® prescriptions flagged for audit, as well as targeted on OptumRx prescription validation requests. The PBMs often target EPIPEN® products due to their higher cost and confusion around proper billing practices and product substitution. Adhering to the guidance below can help avoid billing issues and reduce […]
As the flu shot season starts, PAAS National®® wants to make sure you are ready to properly document these routine vaccines in case of an audit. Now is the time to check that you have all required documentation in place for this year’s flu shot season. What is needed upon an audit:
In the PAAS National®® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024. […]
Calling a prescriber’s office due to a prescription with missing elements, or needing clarification, is an inescapable task. If you are failing to document that phone call with a valid clinical note, PBMs may flag the claim upon audit and try to recoup. We have seen OptumRx, Humana, Navitus, and ESI/Prime results citing pharmacy clinical […]
If you are a DMEPOS supplier billing Medicare Part B claims, then you should be familiar with the proof of refill request requirement. All DMEPOS items and supplies billed to Medicare Part B that are delivered or mailed require proof of refill request and an affirmative response to occur and be documented prior to shipment. […]
