Titration prescriptions are a common target for PBMs seeking to recoup claims, often citing “overutilization,” “refill too soon,” “therapeutic duplication,” or “clinical misuse.” While billing two separate prescription numbers (and/or NDCs) may allow both claims to adjudicate on the same day, plans typically expect…
PAAS National®® continues to see audits being flagged with “Bypassing Plan Limits”. When billing claims, it is very important to pay close attention to these rejection messages, as ignoring them could cost you during an audit. There are several reasons why a pharmacy may see this discrepancy in an audit, including:
PAAS National®®® analysts strive to assist pharmacies in providing accurate and efficient responses during the documentation review process for an audit. It is helpful for analysts to have simultaneous access to both the prescription and billing information, as the audit review is conducted in a manner consistent with remote verification practices. PAAS recommends submitting your […]
PAAS National®® analysts continue to see as needed migraine medications undergo increased scrutiny during audits, and unfortunately, the auditors are (too often) successful in their recoupment efforts.
PAAS National®® frequently emphasizes the importance of accurate documentation for Submission Clarification Codes (SCCs) and Drug Utilization Review (DUR) codes. This is not just best practice, it is essential to protect your claims. Audit chargebacks due to improper or unsupported override codes are notoriously difficult to appeal; therefore, it’s critical to proceed with caution. Lack […]
PAAS National®® recommends attention to detail when it comes to typing directions for patient labels. Pharmacies are often very familiar with prescribers and what they likely intended to include on the prescription, but didn’t. This can range from a specifying a quantity to providing detailed patient instructions. Unfortunately,…
Recent CMS audits have brought renewed attention to how PBMs oversee pharmacy billing for bowel preparation kits. Common issues listed below are leading to potential compliance violations and recoupments. Pharmacies and PBMs alike are urged to review current practices to ensure alignment with federal guidelines and reduce audit risks. PAAS National®® is seeing the following […]
Off-label use refers to the practice of prescribing a medication for a purpose, dosage, patient group, or form of administration that has not been approved by the FDA.
Spravato® (esketamine) is a prescription nasal spray approved for treatment-resistant depression (TRD) and major depressive disorder (MDD) with suicidal thoughts. Due to its potential for misuse and serious side effects, Spravato® is subject to strict handling, administration, and monitoring requirements under the FDA’s Risk Evaluation and Mitigation Strategy (REMS).
Did you know that you can save time by searching past Newsline articles to find answers to your common questions? In fact, the Newsline archive offers articles going back to 2016! The search feature makes it simple to find that one article you know you read a while ago, but can’t seem to remember what […]
