Insurance Billing Question?

[fishert16]

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Okay guys I have a relatively simple questions to ask. If patient HA presents to your pharmacy with a prescription for metoprolol 50mg (specifics do not matter) # 60. You check your shelves and see you have #27 (again the number doesn't matter as long as it is <60), now if I choose to bill the insurance and run the claim for #60 and give the patient #27 and tell them to pick up the remainder tomorrow when the truck comes in.

Is this legal to do? You are in a sense billing for a service that the customer has not received and you are "assuming" they will come and pick it up and that you will get it in. Is my thought process wrong?

Thanks guys

 

[Doctor M]

Okay guys I have a relatively simple questions to ask. If patient HA presents to your pharmacy with a prescription for metoprolol 50mg (specifics do not matter) # 60. You check your shelves and see you have #27 (again the number doesn't matter as long as it is <60), now if I choose to bill the insurance and run the claim for #60 and give the patient #27 and tell them to pick up the remainder tomorrow when the truck comes in.

Is this legal to do? You are in a sense billing for a service that the customer has not received and you are "assuming" they will come and pick it up and that you will get it in. Is my thought process wrong?

Thanks guys

cant bill for a service you havent provided. Being a generic, will cause minimal problems, but you should get in the habit of doing everything the same. Back it out (cash it out), give a partial, and get the product in the next day.

 

[pezdispenser]

Most insurances accept the specific NCPDP partial fill function. You need to find out where it is in your computer system and use it.

 

[fishert16]

cant bill for a service you havent provided. Being a generic, will cause minimal problems, but you should get in the habit of doing everything the same. Back it out (cash it out), give a partial, and get the product in the next day.

I agree and this specific instance did not happen, I am actually on rotation at an independent that does this regularly. We happened to be out of something today and this is the first time this has come up at this site, so I asked what they typically did. He bills for the whole thing, dispenses what he has and has them come back to pick up the remainder. I mentioned this may be illegal (thats what we are taught) for insurance fraud. He and his lead tech laughed in my face.

Most insurances accept the specific NCPDP partial fill function. You need to find out where it is in your computer system and use it.

I am well aware of this function and how it works at my store where I work, but this independent does not use this function. Does anyone happen to know where I can look to find definitive proof of this law/requirement?

Thanks

 

[Doctor M]

I agree and this specific instance did not happen, I am actually on rotation at an independent that does this regularly. We happened to be out of something today and this is the first time this has come up at this site, so I asked what they typically did. He bills for the whole thing, dispenses what he has and has them come back to pick up the remainder. I mentioned this may be illegal (thats what we are taught) for insurance fraud. He and his lead tech laughed in my face.



I am well aware of this function and how it works at my store where I work, but this independent does not use this function. Does anyone happen to know where I can look to find definitive proof of this law/requirement?

Thanks

It is not a law but merely a procedure that is followed according to your contract with the PBM. We back out the claim, cash it out, order the product, update the date to the date the product comes in, rebill the insurance and dispense the product. After a few audits, i learned my lesson!

 

[SoylentGreen]

What happens if the remainder doesn't come in the next day? There are so many generic shortages, you'd better be careful you don't bill for something you can't provide.

 

[Doctor M]

What happens if the remainder doesn't come in the next day? There are so many generic shortages, you'd better be careful you don't bill for something you can't provide.

You simply bill for what you can provide.

 

[Ackj]

Most of the time we'll give a few tablets at no charge, and they pay when the remainder comes in. Exceptions are for expensive products, or things that they're not likely to come back for. For example, we had a patient who wanted 3 boxes of Restasis, but we only had 1 at the time. We had them pay for 3, just because we didn't want to risk them not returning and having that first box go for free. The other case is usually short-term acute treatments, like abx or sometimes pain meds. It is pretty likely that the patient will take their first few days of the treatment, feel better, and not want/need the rest of it. We charge them up front, and if they don't come back, we adjust the claim to be what they actually received. Most of the time the copay will stay the same, since both claims are <30 days and the same drug so it stays in the same tier.

 

[Doctor M]

Most of the time we'll give a few tablets at no charge, and they pay when the remainder comes in. Exceptions are for expensive products, or things that they're not likely to come back for. For example, we had a patient who wanted 3 boxes of Restasis, but we only had 1 at the time. We had them pay for 3, just because we didn't want to risk them not returning and having that first box go for free. The other case is usually short-term acute treatments, like abx or sometimes pain meds. It is pretty likely that the patient will take their first few days of the treatment, feel better, and not want/need the rest of it. We charge them up front, and if they don't come back, we adjust the claim to be what they actually received. Most of the time the copay will stay the same, since both claims are <30 days and the same drug so it stays in the same tier.

Yeah, Brand names are different case.