Medicare Billing for Insulin Pump Therapy

Pharmacies billing insulin vials for eligible Medicare patients must pay extra attention to ensure proper coverage. Since the frequency of dispensing insulin vials has greatly decreased due to the introduction of insulin pens, it is very important pharmacies take a pause and investigate how the patient is utilizing the insulin vials.

Medicare covers insulin vials both for self-administration via injections and when used in an insulin pump. When used in a pump, pharmacies must determine if Medicare Part D or Part B is appropriate. Confirming the correct billing falls on the shoulders of the pharmacy as the Medicare D plans will not reject claims at the point of sale. Incorrect billing is often not identified until months or even years down the road with limited ability for pharmacies to rebill.

PAAS National® has created a tool for pharmacies to help determine which Part of Medicare to bill. Considerations for Billing Insulin Vials: Medicare Part B vs Part D can be found on our website under Proactive Tips. Sharing this guidance with your pharmacy staff can help avoid costly recoupments.

PAAS Tips:

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  • When receiving a prescription for insulin vials, PAAS recommend verifying the following:
    • Is the patient Medicare eligible?Is the prescription for rapid-acting insulin?Is the patient receiving insulin syringes?
    • Is the patient using insulin in a pump?
  • Insulin used in a disposable (tubeless) pump does not meet Medicare Part B coverage criteria, therefore can be billed to Medicare Part D
    • Omnipod®, V-Go®, and CeQur Simplicity™ are examples of disposable insulin pumps
  • Insulin used in a durable (tubed) pump, for a patient that meets Medicare Part B coverage criteria, would be billed to Medicare Part B
  • Pharmacies that are not Medicare Part B suppliers are still required to follow these guidelines
  • Medicare Advantage Plans can be billed for insulin vials regardless of method of administration
  • Long-acting, pre-mixed or concentrated insulins are not approved to be used in insulin pumps
  • See the following Newsline articles:

Oral Inhalers – What You Need to Know About Institutional Pack Sizes

Oral inhaler prescriptions are frequently targeted for audit by PBMs because of their cost, frequent billing errors (e.g., incorrect days’ supply), or prescribing errors (e.g., non-mathematically calculable directions or incorrect written quantity). Vague written quantities can cause recoupments when multiple package sizes exist, including institutional package sizes.

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Institutional size packages primarily exist to allow pharmacies to dispense a smaller package for acute care and institutional settings. The existence of these products can cause audit discrepancies when a prescription is written for a quantity of “1 inhaler” or “1 unspecified.” Many retail pharmacies have expressed to PAAS National® that they cannot order the institutional size packages, so they assume billing one inhaler at the retail quantity is sufficient – auditors disagree. If multiple package sizes exist (including institutional size packages), an auditor will insist that they do not know what quantity the prescriber intended and require you to obtain a prescriber statement clarifying the quantity on appeal.

How can you preemptively avoid this situation? PAAS has updated our Oral Inhalers Chart to include a column for institutional size packages and their billing units. Train your technicians to look closely at the written quantity on the prescription. Does it make sense for the package size being dispensed? If the quantity is written for “1 inhaler,” is there an institutional size package or an additional package size to be considered? Clarify any incorrect, unspecified or ambiguous quantities with the prescriber and document a clinical note on the prescription prior to dispensing.

PAAS Tips:

  • Written quantities on a prescription should contain the proper billing unit of measure (UOM) per NCPDP guidelines, especially if multiple package sizes exist
  • Pay close attention to electronic prescription quantities which have the biggest potential for incorrect or “unspecified” UOM
  • Other prescription origins (written, fax, and transfer) may need clarification for missing UOM
  • Notating UOM on all telephone orders would be considered the best practice
  • Clinical notes should contain the date, the name and title of who you spoke with, a summary of your discussion, and your initials
  • Download the Oral Inhalers chart for the information on package sizes and other useful information like number of puffs per package, beyond use dates, and days’ supply calculations
  • Review our December 2024 Newsline article, 2024 Self-Audit Series #10: Nasal and Oral Inhaler Prescriptions, for more tips on audit-proofing your oral inhalers

Is Your Pharmacy Prepared for a Cyberattack?

In this episode of The Bottom Line Pharmacy Podcast, Scotty Sykes, CPA, CFP and Austin Murray sit down with Trenton Thiede, President of PAAS National®, to unpack the rising cybersecurity threats facing independent pharmacies and what owners must do to stay compliant and protected.

We dive into:

  • HIPAA compliance updates
  • AI risks, multi-factor authentication, and risk assessments
  • The growing pressure of PBM audits and the need for strong advocacy

Tune in by clicking on one of the links below:

FDA Approves First Rapid-Acting Insulin Biosimilar: MerilogTM (insulin aspart-szjj)

On February 14, 2025, the FDA approved the first rapid-acting insulin biosimilar, MerilogTM (insulin aspart-szjj) manufactured by Sanofi Aventis. MerilogTM is expected to reach the U.S. market in July 2025 and will require prescriber approval before pharmacies can substitute for other insulin aspart products such as Fiasp® or NovoLog®.

MerilogTM is the third insulin biosimilar approved by FDA (along with RezvoglarTM and Semglee®).

PAAS Tips:

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  • Review the November 2024 article, Understanding Biologic Substitutions – New Tool Available! for a refresher on terms used to describe biologic products such as reference product, biosimilar, and interchangeable
  • Remember to document prescriber approvals for substitution with a clinical note on the prescription or in your pharmacy software

Audit and Appeal Due Dates: Stay Ahead of the Clock with These Essential Tips

Pharmacy practice often revolves around meeting tight deadlines. Prioritizing can become challenging when you’re focused on providing prompt service to waiting patients or rushing to meet inventory ordering deadlines, all while managing your daily tasks. It’s tempting to push aside a PBM audit request, or its results, to tackle more immediate responsibilities. Unfortunately, neglecting audit or appeal due dates can lead to significant, and unnecessary, financial losses to the PBMs.

One of PAAS National®’s top priorities is helping pharmacies navigate the audit process successfully from start to finish. Remember to engage PAAS early by submitting your audit notice or audit results as soon as you receive them. Discussing your audit notice or results with your assigned analyst early can help you avoid unnecessary work when putting documentation together. This can also eliminate providing unnecessary information to auditors.

A great way to begin is by establishing a workflow process when audits are received. The following tips can assist you with a more efficient and effective audit outcome.

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Step 1: Audit Notice or Audit Results Received

  • Dedicate a specific area for audit documents and inform pharmacy staff of what to do when audit notices are received
  • Send your audit notice or audit results to PAAS as soon as you receive them
  • Discuss with your PAAS analyst the appropriate documents needed for response
  • Contact an auditor/PBM as soon as possible if you feel an extension may be needed
  • Set calendar reminders for audit and appeal due dates

Step 2: Prepare your Documents

  • Gather documents and organize in order of audit request
  • Always number your pages for easier reference for you, your PAAS analyst, and the auditor
  • When signature logs are requested on a separate list, keep those separate in your documents

Prescription Documents

  • While many audits request multiple dates of fill, only one prescription hardcopy is necessary for each Rx#
  • When printing electronic images of prescriptions, be sure to include any electronic clinical notations in your system for auditor to view
  • Reminder all clinical notes should include:
    • Date
    • Name and title of agent you spoke with
    • Specific information that was provided
    • Initials of pharmacy employee that made the call
  • Include any supporting documentation for DUR or SCC overrides
  • When backtags or labels are requested, these can be added to the same page as the prescription
  • Be sure backtags or labels do not cover any prescription elements
  • Keep backtags or labels in same orientation as prescription
  • Unless otherwise indicated, redact any pricing information

Signature/Delivery Requests

  • Always confirm if audit is requesting signature/delivery logs
  • Signature/delivery logs must include:
    • Rx number
    • Date of fill (or fill number)
    • Date dispensed
    • Patient/patient representative signature
  • Redact any PHI not on audit request

Proof of Copay Collection

  • Proof of copay collection is only needed when an audit specifically requests
  • Point-of-Sale transactions, register receipts, or A/R account invoices showing how payment was made may be necessary for responses
  • When secondary payors are involved, be sure to include claims data

Step 3: Submitting your Audit

  • Audit requests provide specific instructions on how to submit your documents
  • While faxing is typically an option, sending large audits this route is generally not advisable
  • Sending via secure email or uploading to a portal are the best recommendations

Step 4: Audit Outcome

  • Keep eyes open for audit results and inform staff of what to do when results are received
  • Set calendar reminder to follow up on audit status when results are not received on a timely basis
  • Remember, checking on your audit results will not change their outcome and may prevent you from missing an appeal deadline

Audit Results and Appeal

  • Audit appeals are individualized for each PBM and discrepancy
  • Review results closely for appeal deadlines as these vary per PBM
  • Involve your PAAS analyst right away as appeal documentation may take additional time and effort to obtain
  • Sending in your appeal documentation for your analyst review can be very helpful to identify any missing or incorrect information

PAAS Tips:

  • Send your audit notice or audit results to PAAS right away
  • Follow the PAAS National® guidance for Getting Help with an Audit
  • Submit audit notice, results or documents for review by uploading to our portal, faxing or emailing
  • When sending electronically, be sure to send as one aggregated file with numbered pages
  • If you send multiple attachments via fax or email, be sure each attachment is clearly labeled
  • Consult our Call Center if you need assistance with submitting your documents
  • Keep your PAAS analyst engaged on any updates or additional requests for your audit
  • Consider training additional staff to assist with your audits as a back up

Mailing Prescriptions? How to Ensure Audit Success

While some pharmacies make mailing prescriptions a regular practice, others may only do so on a case-by-case basis. PBMs require signature logs to prove that a patient received their medication in a timely manner, but how is proof obtained when the patient is not standing in front of you at the pharmacy counter?

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PBMs will require proof of delivery that contains information clearly showing what was in the package delivered. Most PBMs require a link between the delivery confirmation (via a tracking number) and the prescription record to show which prescription was being delivered. There should also be a patient signature or tracking detail from the carrier showing the date and location where the medication was ultimately received.

Notably, not all PBM agreements allow the mailing of prescriptions, while others may restrict mailing to a percentage. Humana and OptumRx typically prohibit mailing under retail agreements, and OptumRx further restricts delivery to within 100 miles by W-2 pharmacy employees. Caremark only allows up to 20% of their claims to be mailed.

Another consideration for pharmacies is ensuring you are licensed in any state you are mailing to. Many states have laws that require pharmacies to obtain a non-resident license to ship, mail, deliver, or dispense prescription medications into their states. Auditors look for these [expensive] claims to take advantage of well-meaning pharmacies who may not know of these requirements. Pharmacies located on state borders making deliveries into another state may also run into this problem as well.

PAAS Tips:

  • Have a system that links the tracking number to the prescription record to indicate the contents being shipped.
  • Print confirmation of delivery and keep it in a readily retrievable manner for audit – some carriers only keep tracking information for as little as 120 days, depending on the service used.
  • Before mailing/delivering prescriptions out of state, it is a good idea to check with that state’s Board of Pharmacy to see if there are any licensure requirements for doing so.
  • Be aware of your contract obligations and which PBMs do not allow mailing prescriptions to patients.
  • For all DMEPOS items and supplies billed to Medicare Part B, proof of refill request and an affirmative response is required to occur and be documented prior to shipment.
  • PAAS’ Proof of Refill Request and Affirmative Response for DMEPOS Items can be downloaded from our portal.
  • If you do not require signatures upon delivery, consider providing the patient with a copy of our Signature Log Trifold Mailer to sign, fold up, and mail back to the pharmacy.
  • Some PBMs, like Navitus Health Solutions, require a signature regardless of tracking information.
  • See the March 2025 Newsline article, Will Your Signature Logs Pass an Audit? for information on what auditors look for when patients pick up their medications or have them delivered.

Audit Considerations for Med Sync Programs

Medication synchronization (med sync) programs are common across pharmacies and yield many benefits. Patients can request it to manage medication better and reduce the number of trips needed to the pharmacy. Patient adherence increases and pharmacies can keep tighter control over inventory while having more efficient workflow.

NCPA promotes the improved adherence and quality of care through med sync programs. They call it a “once a month appointment day” for patients enrolled, saying pharmacist-patient dialogue increases with more time to focus on additional patient care services.

NCPA collaborated with the Arkansas Pharmacists Association to conduct a study measuring the impact of med sync programs on medication adherence and persistence across 82 independently owned pharmacies. The workflow tool was provided to the pharmacies by PrescribeWellness operating on 13 pharmacy management systems. Over 8,000 patients enrolled for this year-long retrospective cohort study. The key findings state that med sync patients are over 2.5 times more likely to be adherent to medications and 21% less likely to discontinue drug therapy. For more details, see the Study Overview and Full Report.

It’s a win all around – until it poses a waste or abuse issue. PBM audit algorithms are made to seek out fraud, waste, and abuse. PBMs will flag pharmacies for audit if claims are billed particularly early every month; for example, every 23 days on a 30 day’s supply.

PAAS National® recommends …

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having patients opt in for med sync with a signature that can be produced under audit, ideally with annual reverification. This way the pharmacy has evidence to support the patient requested enrollment. This enrollment should also include guidance on how a patient may ‘opt-out’. Med sync best practices also include a phone call [preferably documented] every month to affirm the refills needed prior to dispensing. Cycling the refills at ≥ 90% utilization can also help lower your risk of audit triggers from PBM algorithms that look closer at 75% utilization. Avoid putting bulk items on med sync, such as inhalers, insulin, eye drops or topicals. Med sync also shouldn’t apply to prescriptions written for as needed purposes or controlled substances.

PAAS Tips:

  • State pharmacy regulations may prohibit automatic refill programs or require additional documentation
  • Payer restrictions may apply for programs such as Medicare Part B/D and Medicaid
  • Automatic mailing and delivery of prescriptions often have additional requirements
  • Read Getting in Sync from NCPA’s America’s Pharmacist February 2024
    • See also the Pharmacy Operations Manual for SimplifyMyMeds® from NCPA February 2018

Respiratory Syncytial Virus (RSV) – What You Need to Know

There are currently three FDA-approved Respiratory Syncytial Virus (RSV) vaccines available for individuals at risk of severe illness from a respiratory virus. Please review the chart for helpful billing tips and the additional information below as to which RSV vaccine is appropriate to give to an eligible individual.

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Trade nameManufacturerNDCNCPDP Billing UnitSuggested Days’ SupplyTime to administer
 Abrysvo®*Pfizer00069-0344-011 EACH1 day supplyUse within 4 hours after reconstitution
   Arexvy®GSK58160-0848-11
mRESVIA®**Moderna80777-0345-900.5 MLUse within 24 hours after thawed at room temperature

*Also available in 5 and 10 kit packages       **Also available in a pack of 10 pre-filled syringes

  1. Abrysvo®
    1. 60 years of age and older
    1. Pregnant women at 32 to 36 weeks gestational age
    1. 18 – 59 years of age who are at an increased risk
  2. Arexvy®
    1. 60 years of age and older
    1. 50 through 59 years of age who are at an increased risk
  3. mResvia®
    1. 60 years of age and older

The CDC recommends a single dose of any FDA licensed RSV vaccine be given to all adults ages 75 and older and adults who are between the ages of 60 and 74 who have an increased risk of severe RSV. The conditions that increase the risk of severe RSV can be found on the CDC website. The CDC also recommends pregnant women receive a dose of the maternal RSV vaccine (Abrysvo®) during weeks 32 through 36 of their pregnancy sometime between September through January.  To prevent severe RSV in infants, it is recommended that the mother receive the maternal RSV vaccination or the infant receive the vaccination with RSV monoclonal antibody.

PAAS Tips:

  • Be cautious when billing mRESVIA® as each pre-filled syringe is billed as 0.5 mL versus the Abrysvo® and Arexvy® vials which are billed as 1 EACH
  • Medicare covers RSV vaccine under Part D
  • Pharmacists play a key role in educating high-risk patients on RSV prevention
  • Eligible patients can receive the RSV vaccine at any time, but the best time to vaccinate is late summer or early fall before RSV starts to spread
  • Like all vaccines, pharmacies should maintain documentation in case of an audit:
    • Authorization to administer, which may include a patient-specific prescription or a collaborative practice agreement (CPA)/protocol
    • Signed prescription or placeholder prescription (when using a protocol or CPA)
    • Vaccine Administration Record (VAR)
    • Screening checklist
    • Vaccine Information Statement (VIS)

Medicare Part A vs Part D Billing Risks – How to Protect Your Claims

Pharmacies continue to receive PBM audit notices for claim recoupments where the [allegedly] improper Medicare coverage was billed. Medicare Part A helps cover hospital, skilled nursing facility (SNF), and hospice care stays. Medicare coverage status is typically linked to the patient’s admission and discharge dates from a Part A stay.

When a patient is covered under a Part A stay, the facility providing the stay is typically paid a per diem for the medications, supplies, and services needed during the coverage period. This means that Medicare Part D cannot (and will not) be responsible for claims billed during that time. Unfortunately, PBMs typically do not have the information at the point of sale to stop these claims from being billed inappropriately, leaving pharmacies scrambling upon retrospective review/audit.

PAAS Tips:

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  • Work with your contracted facilities to have a process in place for them to notify you of a patient’s Medicare status change
  • Have an agreement in place, with the facilities you service, on how payments can be settled if claims were incorrectly billed to Medicare Part D and subsequently recouped
  • Medications billed to Part D but delivered to facilities when a patient is “in-patient” (under a Part A stay) should be returned to the pharmacy (or rebilled accordingly)
    • Per the Medicare Benefit Policy Manual claims can be billed once again to Part D on the day of discharge (see also SCC = 57 below)
    • Any sooner and the claim would face full recoupment – even if there is only one day of overlap
    • Stay informed for delays of patient discharge – if the patient has not left the hospital or SNF prior to their checkout time, the Part A facility may charge the beneficiary for another day of stay
  • Questions asked during medication pick up may assist pharmacies on knowing if, or when, the patient will be discharged
  • LTC patients’ medications may need to be split-billed when the patient is moved from a Medicare Part A to Part D stay
    • Using submission clarification code 19 (Split-Billing) indicates the remainder of the claim being billed is no longer eligible under Medicare Part A stay. This code should only be used in an LTC setting.
    • Using submission clarification code 57 (discharge medication) indicates the dispensed medication is for a patient’s discharge from a facility.
  • If you receive a notice from Medicare D for incorrect billing due to a Medicare Part A stay, send it to PAAS National® for guidance

Changing Pharmacy Management Software? Don’t Neglect Record Retention!

When updating or changing pharmacy management software systems, pharmacies may be presented with different options to archive the files from the software they will no longer be using. While it may not seem worth the extra cost now, ensuring that you are able to retrieve appropriate data for old claims is crucial to avoiding costly audit results in the future.

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Does the option you are selecting ensure you’ll be able to easily retrieve and provide copies of any required information? Prescriptions, claim data billed to the insurance, signature logs, proof of copay collection and invoice records are all items that a pharmacy would need to be able to access whenever needed. Not only for auditing purposes, but to stay within contractual record keeping requirements as well. Medicare Part D rules require all records to be retrievable for 10 years, plus the current contract year; while Commercial plans, Medicaid, state, and federal requirements can all range from 2 to 7 years.

If you can produce documentation from your old system – great! Will the details pass an audit? Ensuring that prescriptions and other documentation from an old system have all necessary elements and are not missing things like unit of measure, clinical notes, or the pickup date on a signature log is important and can save a pharmacy from having to appeal. This is also a consideration when acquiring another pharmacy’s records. Be aware of potential audit hazards with newly acquired records. Origin codes, state transfer requirements and clear links to original prescriptions should be considered during the acquisition process.

PAAS Tips:

  • Ensure you can readily retrieve and print all electronically archived documents in a useable format
  • Have access to technical support when using any software vendor to avoid technical difficulties
  • When acquiring records or switching to a new system, this typically requires an update to the prescription’s origin code [5], as well as having a clear reference to the original prescription (i.e., crosswalk for data migrations)