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.
One of the reasons insulin claims for Medicare Part D patients are commonly audited is because the PBMs can’t identify if the patient is self-administering (and Part D is responsible) or using in a pump (where Part B may be responsible) at adjudication. PBMs may isolate insulin claims if a member does not have any syringes being billed to Part D along with their insulin. The pharmacy should always verify with the patient or prescriber if insulin is being used in a pump.
Billing the wrong type of insulin for a pump can also result in large audit recoupments. See the tips below for which insulin types should, and should not, be used in an insulin pump.
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