Are You Familiar with Qualified Medicare Beneficiary (QMB) Billing Obligations?
Qualified Medicare Beneficiary (QMB) is a program for patients that have Medicare Parts A and B coverage and qualify for additional coverage through Medicaid.
Entries by Dana Westberg, CPhT
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 […]
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 […]
2024-2025 Self-Audit Series #12: Electronic Prescriptions
This month’s article will wrap up the 2024-2025 Self-Audit Series. Our focus for this article is electronic prescriptions and their potential audit risks. Electronic prescriptions have solved some problems (e.g., indecipherable handwriting), but have also created new problems. By focusing on the following tips when reviewing your electronic prescriptions, you can help prevent significant recoupments. […]
2024-2025 Self-Audit Series #11: Controlled Substance Prescriptions
The opioid epidemic continues to make controlled substance prescriptions an increased focus for PBM audits. The potential for fraud, diversion, overdoses, and abuse remains high and pharmacies must stay vigilant when dispensing these prescriptions. Due to federal and state requirements, controlled substance prescriptions have an increased risk of audit discrepancies. When found discrepant, PBMs typically […]
2024 Self-Audit Series #10: Nasal and Oral Inhaler Prescriptions
Nasal and oral inhaler prescriptions are frequently targeted for audit by all PBMs. Not only have these medications increased in cost but are frequently billed incorrectly, creating the potential for easy recoupments. Pharmacy staff should be trained to accurately bill days’ supply for all inhalers. PAAS National®® has created tools for our members to aid […]
2024 Self-Audit Series #9: Eye Drop Days’ Supply
Billing the accurate days’ supply for eye drops can be challenging. Despite what is drilled into pharmacists during schooling, there is no industry standard for drops/mL, and PBMs often use their own specific conversion factors.
Self-Audit Series #8: Compound Prescriptions
Compound prescriptions may not be a frequent occurrence for some pharmacies; however, those that do bill compounds must be aware of the audit risks.
Medicare and Vaccine Billing: What You Need to Know
Pharmacies need to be aware of the risks of billing claims [to Medicare B/D] for patients under a Medicare Part A stay.
Quantity Written vs Quantity Dispensed – Are You Covered?
PAAS National® analysts continue to see audit results flagging “unauthorized refills” or “excessive quantity billed”.
