Avoiding MedImpact Recoupments for Bypassing Plan Limits
Pharmacies receive many rejections while billing claims throughout the day. Paying attention to these rejection messages is key to avoiding audit recoupments, which may occur years later.
Entries by Jenevra Azzopardi, CPhT
Documentation Deep Dive: Meeting Auditors’ Standards in DUR and SCC
PAAS National® frequently sees claims audited that contain a clinical drug utilization review (DUR) or submission clarification code (SCC), particularly from Express Scripts and Prime Therapeutics.
Calculating Days’ Supply – Pancreatic Enzymes
Auditors target pancreatic enzyme prescriptions like Creon® and Zenpep® due to high cost and ambiguous directions.
Signature Required – Proving Patient Receipt
The Public Health Emergency for COVID-19 ended on May 11, 2023, and PBMs notified pharmacies that they would once again be requiring signatures for proof of patient receipt of medications.
Automatic Prescription Refill Concerns
Many pharmacies use an automatic refill process to streamline the labor needed to fill prescriptions.
Are You Ready for Flu Shot Season? Auditors Are!
It is that time of year again; flu shot season is upon us. As busy as this season can be, we know you do not want to worry if you have all the documentation you need in case of an audit.
Electronic Clinical Notes: Are They Required?
There has been some discussion in pharmacy circles about clinical notes and whether PBMs are requiring them to be electronically annotated (or if hand-written clinical notes will continue to suffice).
Billing Test Claims? It Can Cost You!
We have all been there – a prescriber calls the pharmacy to find out which prescription from a therapeutic category will be the most cost-effective for the patient.
Incorrect NDC or NPI Billed? Humana Requires Corrections
Humana has recently sent out another round of audits where either an incorrect NDC number or National Provider Identifier (NPI) was billed.
At Your Own Risk: “Use as Directed”
How many times have you received a prescription for a bowel prep, starter pack, or pre-packaged taper where the directions simply state, “Use as Directed?”
