Pharmacies may receive requests to determine if a specific medication is covered on formulary or what the copay will be in the absence of an actual prescription. While this may seem like a harmless request, “test claims” are generally prohibited by third-party payers. If your pharmacy submits a claim to insurance without a prescription, a PBM could cite this as a false claim or even fraud.
Payer concerns with test claims include:
- A pharmacy forgets to reverse the claim and is paid for a prescription that does not exist, was never purchased, nor dispensed
- A “bad actor” pharmacy could develop a Fishing Scheme – looking for coverage of high margin drugs, then solicit/market these to patients with the same coverage
- Avoid Test Claims – only transmit claims pursuant to a valid prescription
- Any claim billed to third-party payer should have a corresponding prescription in your records. If the claim is rejected, or the patient elects to not fill the prescription (and requests the hardcopy back), you still need to maintain a copy of the prescription for audit purposes
PBM audits for rejected or reversed claims are uncommon but may put your pharmacy at risk.