Wiki Pharmacy Billing

[beachbum729]

Hi, I work for a Family Planning Provider. We normally bill all contraceptives and Medications to the RX payer if the patient has one. They are now looking into billing the Commercial insurance first BEFORE billing the RX because of a higher level of reimbursement. I do not think they are able to do this. Can anyone assist me in where I can go to get back up that this should not be done? Thanks Much

 

[thomas7331]

Hi, I work for a Family Planning Provider. We normally bill all contraceptives and Medications to the RX payer if the patient has one. They are now looking into billing the Commercial insurance first BEFORE billing the RX because of a higher level of reimbursement. I do not think they are able to do this. Can anyone assist me in where I can go to get back up that this should not be done? Thanks Much

I don't think your clinic will have a choice in this matter - different types of drugs given in different settings will be covered under one plan or the other, but not both, so you will need to bill the plan where the patient's coverage is. This is going to be driven by payer-specific policies, contracts and by how the patient benefit plans are set up, so I would recommend you look first at the policies of the payers, review your contracts and talk to you network representatives for guidance on this. The patient's benefit documents should also explain whether a given drug, or a given service, is covered by the medical plan or the pharmacy plan. As a general rule, most commercial plans will not reimburse self-administered drugs under a medical benefit plan, so for those, you will have no choice but to bill the pharmacy plan, otherwise you will just get a denial. If the drug is administered in your clinic or by your physicians, the situation may be a little more complicated and you may be able to bill for the drug to the medical plan along with the administration service on the physician's claim, but depending on the drug there may be other requirements such as authorizations or medical review that you will have to deal with before the claims will be paid, so it may or may not be the best route to go. I would definitely not just start billing the medical plan without doing all the necessary research first as that could end up creating a real mess for your billing department.