In our August Newsline Standard Written Order and Medicare Part B Audit Risks – New Guidance, we shared a few examples some of our members are having on audit results regarding their Standard Written Order (SWO). Beyond writing the Newsline, PAAS National® also reached out and engaged nurse medical reviewers with CGS about our concerns on the three topics below.
PAAS National® analysts frequently receive questions regarding the proper billing of creams and ointments, an easy audit target for PBMs.
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.
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.
See the PAAS tips for best practices on how to track and manage duplicate or high numbers of prescription validation requests.
PAAS National® knows community pharmacies are busier than ever, making it difficult to keep up with all the PBM communications.
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.
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.
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.
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.
