Consider the following situation: after pulling hard copy prescriptions for an audit, a billing error is identified; such as an incorrect days’ supply or billed quantity. The initial thought may be to reverse and rebill the claim – a seemingly reasonable action to take; however, one must resist the urge to reverse the claim.
Depending on the PBM, type of audit and auditor preference, the process given to resolve the incorrect claim may differ. Additionally, reversing a claim outside the billing window, without proper authorization, may result in a claim that is unable to be reprocessed. There are also unique exceptions to the guidance of not reversing the claim prior to obtaining direction. For example, some audits of recent claims may include explicit instructions to correct claims if any errors are found. To save time and avoid costly mistakes, Engage PAAS National®® upon receiving an audit notice.
- Review the September 2019 Newsline article, Claim Reversal Best Practices
- If given permission by the auditor to reverse and rebill the claim, include a print screen of the adjudication reflecting the claim was reversed and subsequently rebilled correctly
- Respond to the audit unless explicitly told otherwise
- Sometimes “final results” are given for small desk audits with claims submitted shortly before the date the audit was issued. This is merely a means of closing out the audit. The recoupment amount reflects the old claim being reversed and it is likely the new claim has a paid status. No action is required by the pharmacy.
- If you want to ensure the plan sponsor has received the corrected claim, call the PBM help desk to inquire