Required: Proof of Patient Copay Collection
All PBM agreements contain language requiring pharmacies to collect copays and be able to prove those copays were collected if audited. Copays are used by insurers to help patients understand the cost of their medications and encourage less expensive alternatives. Pharmacies who reduce or waive copays adjudicated by the PBM risk full recoupment of those claims if audited, and possible contract termination.
How do you prove a copay was collected?
Other things to consider when proof of copay collection is required:
Credit card receipts should include:
- The last four digits of the credit card number
- The transaction authorization number
- The merchant ID number
Payment by check may require copies of cancelled checks, front and back.
Payment by cash may require proof of cash bank deposits being made during the timeframe under audit.
Reduction of copay due to a secondary payer (coupon or secondary insurer) may also require proof including:
- A print screen showing adjudication to the secondary insurer
- Secondary payer plan information like the BIN, PCN, Patient ID, and group number
- Any eVoucher data applied by the switch
- Amount paid and any remaining out of pocket amount
If using a house charge account, you should be able to produce the following:
- Policy and Procedure for collection of monies due on the account
- Documented attempts to collect payment in the form of dated invoices sent to the patient and logged phone calls attempting to collect
- Itemized Accounts Receivable report showing payment received, tying the payment back to the prescription number, and any outstanding balance remaining
If waiving a copay due to financial hardship, you will need objective evidence of that hardship, like an application, tax returns, and a formal written Policy and Procedure. It cannot be advertised or promoted, nor funded, in whole or in part, by a third party. It also must meet all requirements and restrictions of applicable law.
Non-routine, unadvertised waivers of copayments based on individualized determinations of financial need for patients with Medicaid may be acceptable without a financial hardship Policy and Procedure.
PAAS Tips:
- Use an integrated POS system to reduce risk of recoupment
- Copays should be collected at the time of sale as a best practice
- House charge accounts require a strong Policy and Procedure for collection
- Ensure good cash handling policies
- Make bank deposits at regular intervals
- Avoid taking money directly from the register for business expenses
- Balance the register at the end of the day
- See the following Newsline articles for more information:
- PAAS Fraud, Waste & Abuse and HIPAA Compliance members should review section 1.5 – Copay Collection in your Policy and Procedure Manual
- Representative NDC on Electronic Prescriptions Do Not Infer Specificity - November 24, 2024
- Insulin Pens: Understanding Dosing Increments and Audit Risks - October 9, 2024
- What to Do (and Not Do) When Your Days’ Supply is Rejected - October 7, 2024