Bill it Right: AndroGel® Pump 88 g vs 75 g
Pharmacies have recently reported receiving telephone calls from Caremark’s audit department regarding claims for AndroGel® (testosterone) pump (and generics) related to incorrect package size billed.
Entries by Eric Hartkopf, PharmD
Accepting Gifts Can Be an FWA Violation
The U.S. Department of Justice issued a press release on September 30, 2021, outlining that a former public official accepted “gratuities” (aka gifts or kickbacks) in exchange for referring business to a specific outside vendor.
Billing Insulin & Related Supplies – Medicare Part B vs Part D
PAAS National® analysts frequently field questions about billing insulin and related supplies – this can be particularly confusing when the patient has Medicare coverage. Coverage of insulin and related supplies may depend on both the type of Medicare benefit and how the item is being used. Specifically, insulin vials and alcohol swabs could be covered under either Medicare Part B or Part D!
COVID-19 Vaccine Billing Guidance
The coverage for COVID-19 vaccine may be under the pharmacy benefit (via NCPDP standard) or the medical benefit (via CPT codes). Here is a summary of billing information known to PAAS National® as of December 23, 2020.
Caremark Manufacturer Coupon Policy
PAAS National® continues to see pharmacies suffer full recoupment on claims that are processed to coupons and copay cards in violation of Caremark’s policy found in section 3.03.03 of the 2020 Pharmacy Provider Manual.
Nine Pharmacists Charged in $12 Million Fraud Related to Invoice Shortages
Nine pharmacists were recently indicted on felony charges in a $12.1 million health care fraud scheme according to a June 17, 2020 U.S. Department of Justice press release.
BEWARE: Virtual On-Site Audits Are Coming!
If you haven’t already noticed, most of the PBMs have resumed auditing practices and started issuing on-site audits the first week of August; however, these are not the on-site audits that you are used to.
Caremark Enforcement: Aberrant Quantities & Volumes
PAAS is starting to see Caremark enforce their new policy about Aberrant Quantities and Volume that we first wrote about in a December 2019 article Important: Caremark Provider Manual Updates for 2020!.
PBMs Enforcing Return to Stock Policies
It is common practice for PBMs to recoup claims [in full] for medications being picked up after the return to stock timeframes listed in their provider manuals (also known as “unclaimed prescriptions”). Pharmacies with an integrated Point-of-Sale should look to generate a list of prescriptions near the allowed timespan for medications to be left in pick-up bins.
