In last month’s Newsline article, “A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims, PAAS National® provided insight into the revised billing process for multi-payor claims where one payor prefers the brand and the other payor prefers generic. Due to the complexity of this billing process, a new PAAS tool has been developed, Conflicting Coverage: When One Payer Covers Brand and the Other Prefers Generic.
This new tool will provide staff with a billing flowchart to follow when the primary payor prefers brand and a second chart to follow when the secondary prefers brand. These flowcharts can serve as a quick reference guide that can be printed out and posted at the data entry station for easy reference. At the end of this new tool, there is a table with a more in-depth explanation of this multi-payor billing process.
While the majority of the pharmacy’s claims are likely to process through just one payor, it is not uncommon to have a patient with a secondary payor (e.g., Medicaid). While Medicaid as a secondary payor is not the only scenario where this tool will be helpful, it is likely the most common. Primary payors often have different formulary preferences for multi-source brand products than Medicaid due to various manufacturer rebates. PAAS analysts frequently receive questions about the proper way to bill these claims and which DAW code is appropriate to use. While an analyst is always happy to guide you through these scenarios, this tool can be at your fingertips and can also guide you through the process of how to correctly bill these claims.
Find this tool, and other amazing PAAS tools and aids, on the Member Portal. Here you can find Proactive Tips, Days’ Supply Charts, and even On-Demand Webinars! If you are not able to find something you’re looking for, just reach out to a PAAS representative for additional guidance.
What’s New with Prescription Validation Requests in 2025?
In the PAAS National® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024. While we are not surprised that Ozempic® continues to be the top drug on the prescription validation requests, the others are not surprising either.
The top 5 comments noted by an analyst after claim review for the first half of 2025 mirror those from 2024.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Manufacturer Coupons: Why It’s Important to Read the Fine Print
While PAAS National® sees a vast array of PBM audits daily, did you know that claims billed to a manufacturer coupon can also be audited by the coupon administrator? Each manufacturer coupon…
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Fraudulent Prior Authorization Submissions Costs Pharmacy Over $1 Million
A Florida-based pharmacy plead guilty to healthcare fraud and agreed to pay over $1 million to resolve False Claims Act violations stemming from falsified prior authorizations. The pharmacy dispensed Evzio® (injectable naloxone product for emergency treatment of opioid overdose—discontinued in October 2020) which frequently required prior authorizations due to its high cost. Instead of sending the prior authorization information and/or forms to the prescribers, the pharmacy would complete the forms and, in some cases, sign the required forms. It was made to appear that the physician (not the pharmacy) was submitting the information. Pharmacy staff also provided false information to the insurer that the patients had tried and failed to successfully use Narcan®.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Preventing Misfill Recoupments Through Documentation
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,…
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
New PAAS Tool! Flowchart for Multi-Payor Claims with Conflicting Coverage
In last month’s Newsline article, “A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims, PAAS National® provided insight into the revised billing process for multi-payor claims where one payor prefers the brand and the other payor prefers generic. Due to the complexity of this billing process, a new PAAS tool has been developed, Conflicting Coverage: When One Payer Covers Brand and the Other Prefers Generic.
This new tool will provide staff with a billing flowchart to follow when the primary payor prefers brand and a second chart to follow when the secondary prefers brand. These flowcharts can serve as a quick reference guide that can be printed out and posted at the data entry station for easy reference. At the end of this new tool, there is a table with a more in-depth explanation of this multi-payor billing process.
While the majority of the pharmacy’s claims are likely to process through just one payor, it is not uncommon to have a patient with a secondary payor (e.g., Medicaid). While Medicaid as a secondary payor is not the only scenario where this tool will be helpful, it is likely the most common. Primary payors often have different formulary preferences for multi-source brand products than Medicaid due to various manufacturer rebates. PAAS analysts frequently receive questions about the proper way to bill these claims and which DAW code is appropriate to use. While an analyst is always happy to guide you through these scenarios, this tool can be at your fingertips and can also guide you through the process of how to correctly bill these claims.
Find this tool, and other amazing PAAS tools and aids, on the Member Portal. Here you can find Proactive Tips, Days’ Supply Charts, and even On-Demand Webinars! If you are not able to find something you’re looking for, just reach out to a PAAS representative for additional guidance.
Reduce Vaccine Audit Risk Through Accurate Quantity Billed
To enhance profitability, pharmacy owners and operators have frequently incorporated immunization services into their offerings. While vaccines tend to carry a lower audit risk, the higher the cost of the vaccine, the more likely it is to be audited. The audit risk also increases when core billing elements of the vaccine claim are adjudicated incorrectly.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
PBMs Are Criticizing Clinical Notes!
Calling a prescriber’s office due to a prescription with missing elements, or needing clarification, is an inescapable task. If you are failing to document that phone call with a valid clinical note, PBMs may flag the claim upon audit and try to recoup. We have seen OptumRx, Humana, Navitus, and ESI/Prime results citing pharmacy clinical notes. Many of the provider manuals have language on what a valid clinical note should minimally contain. Our experience upon reviewing audit documents, results, and provider manuals is that a clinical note should contain four elements. If the following elements for a clinical note are present, they will reduce an auditor’s ability to recoup upon audit.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Delivering to a Clinic? Avoid Audit Risks!
Traditional dispensing for independent pharmacies continues to transform. Beyond dispensing prescriptions at the pharmacy counter, some pharmacies are providing patient-specific prescriptions directly to clinics for administration. Pharmacies must be aware and protect themselves from the heightened audit risks.
While PAAS National® has written countless Newsline articles on signature, delivery, and mailing requirements to help our members ensure proper documentation is being obtained, additional consideration should be given for medications delivered to clinics for administration. Pharmacies are often under the assumption once the medication is delivered and signed for by clinic staff that their responsibility has ended; however, PAAS has seen many pharmacies run into PBM audit issues where additional controls were absent.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Unannounced CMS Site Visits
PAAS National® has recently seen an uptick in the number of unannounced CMS site visits related to Medicare enrollment or revalidation. These visits are currently being conducted by Novitas Solutions, the contracted National Provider Enrollment East (NPEast) contractor and Palmetto GBA® for the NPWest. Site visits are performed to verify the business location and ensure that suppliers meet DME supplier standards.
Pharmacies will typically receive a notice that indicates a site visit will be forthcoming and that they cannot provide specific information on when the visit will be conducted. The notice includes a list of items to be examined by personnel including, but not limited to, the following:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
From Headache to Hassle Free: Best Practices in Migraine Medication Billing
Migraine medications continue to be targeted for audit by all PBMs. With new products on the market, rising costs, and frequency of refills, PBMs are looking for billing errors to claw back payments on audit.
OptumRx’s latest tactic…
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips: