Third Party Audit Question

[MAbdelgowad]

Hey Everyone,

Quick question: We do a lot of compounding and sometimes due to budget reasons (we are fairly new), we are not able to order the supplies until a week after the prescription was billed.

Therefore, there is a difference in the "bill date" and the actual "fill date." Are Insurance companies ok with that? I never handled audits alone before (this is an independent pharmacy).

Going on, I am trying to bill the day I actually have the supplies, but I do have some backlogged. Is this going to be a problem during an audit?

Thanks!

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[PharFromNormal]

I could see a potential issue in at least one scenario.

If you bill the prescription on 9/1 and they show up to audit on 9/4 for a prescription billed on 9/1 and the patient doesn't have it (and/or you have no record of the patient picking it up) and you don't have it filled on hand because it is being ordered in for 9/10.

I would anticipate it to be much harder to track down retrospectively. I guess they could try and look for fill date vs pick up date and see if you are following proper claims reversal windows. I'm not sure however how much they can actually dig into your inventory records, I would imagine your invoices and drug acquisition information is all off limits.

There's probably better sources of knowledge out there on this though.

 

[Ackj]

I was under the impression that the transaction isn't finalized until it has been sold. That would be the whole reason for the 14 day return to stocks, since those transactions are all just pending in the meantime, waiting for a pickup to finalize or a reversal to cancel. I honestly do not know for sure, that is just what I was always led to believe.

 

[wickedone]

Hey Everyone,

Quick question: We do a lot of compounding and sometimes due to budget reasons (we are fairly new), we are not able to order the supplies until a week after the prescription was billed.

Therefore, there is a difference in the "bill date" and the actual "fill date." Are Insurance companies ok with that? I never handled audits alone before (this is an independent pharmacy).

Going on, I am trying to bill the day I actually have the supplies, but I do have some backlogged. Is this going to be a problem during an audit?

Thanks!

If this is a common practice then you will have an issue. They can do an inventory audit. If you are seriously concerned, its best to ask the insurance company how they will handle it rather than you face an audit and lose 100% of the billed amount.

They have NO concern whether you are new or now. Also, you may want to provide a little bit more detail. Are you billing 1000$ and ordering 50$ in supplies?

Good luck with it but in my experience (owning a specialty independent) its best to not screw the system instead work with it. Just call the insurance company or PAAS national and inquire best way to approach this scenario. If your uncomfortable tell them its hypothetical or call an insurance company you dont work with. PAAS would be a great resource for you.

 

[BF7]

You're phucked. The dates need to match, if verbal rxs the date, time and who called it in followed by the Rphs initials are needed by some PBMs...

Call s company called PAAS.

 

[Old Timer]

As long as you have NOT actually billed the insurance company on the date of service, there is no problem. This is the same as every OOS situation. Bill the rx on day 1. Find it's oos. Reverse claim and bill on day 2, using day 1 as the date of service. You will be fine.