Pharmacies receive many rejections while billing claims throughout the day. Paying attention to these rejection messages is key to avoiding audit recoupments, which may occur years later. One such rejection occurs when a pharmacy bills a claim that exceeds a plan limit. This can be due to:
- Total quantity being over a plan maximum
- Cost exceeding plan limit (e.g., compounds exceeding $1,000)
- Dose exceeds FDA maximum
Actions to consider including …
MedImpact has a history of recouping claims which have been rebilled incorrectly to bypass plan limits. PAAS National® has seen numerous audits on blood glucose test strips where a pharmacy attempted to bill the correct days’ supply, received a rejection stating they will only cover a certain number of test strips per month, then rebilled for that quantity and with a different days’ supply even though it is not mathematically correct. This makes it very easy for MedImpact to come back and audit the claim because they already saw the pharmacy put in one days’ supply, then rebilled for a new days’ supply after receiving a rejection (especially when it occurs within seconds of the first rejection). Audit results will often state, “Incorrect billing of the day supply in order to bypass system edits (or the PA process) is not acceptable. MedImpact will reverse this claim.”
These recoupments can be difficult to appeal. It is better to ensure you are entering the correct days’ supply based on the mathematical calculation of the directions and following plan rejections appropriately at the start of the claim than to try to appeal later.
- All pharmacy staff should be aware of plan rejections and how to work them appropriately without incorrectly billing the days’ supply.
- A conversation with the prescriber’s office may be needed to start a prior authorization or obtain a new prescription with appropriate dosing.
- Document all conversations about the rejection with a full clinical note.
- Consider calling the insurance help desk to see if there are overrides available to use.
- Do not split bill rejected claims which can lead to patient complaints and potential network termination for non-compliance with a provider manual.
- Documentation is recommended if a patient insists on paying cash for the full prescription, including their authorization and that they will not seek reimbursement from their insurance.
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