If you are a Medicare Part B supplier, then you have likely had an audit on diabetic test strips. Billing Medicare Part B is quite different than other payors, and consequently, can be very challenging for pharmacies.
Since Ozempic® was FDA approved December 5, 2017, PAAS National® has fielded many questions regarding dispensing this expensive injectable diabetic medication.
PAAS National® often sees recoupments on ostomy supplies due to unsupported medical records.
Pharmacies often struggle with audits for DMEPOS items. The Medicare Part B/DMEPOS billing model is a complex maze of units, codes and documentation requirements that are very different from billing traditional prescription drugs.
Insulin is a very popular audited drug category due to its complexity, frequency of use, and high cost. When used in conjunction with an insulin pump, it adds another layer of complexity.
Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims – if you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems.
On March 13, 2020, HHS authorized many waivers and modifications regarding Medicare Part B and DMEPOS claims to help prevent gaps in access to care for patients affected by the PHE.
Due to the high volume of claims for diabetic test strips, they continue to receive significant attention during third-party audits. Follow the tips below to be prepared if you get an audit.
PBMs have dramatically increased the number of invoice audits conducted and some pharmacies continue to be at risk for significant financial recoupments and contract terminations.
Many of the denied claims are due to not meeting medical necessity, frequency limitations, lacking supporting medical records and even basic coding mistakes.
