Nebulizer Medications: Part B vs Part D

[Sparda29]

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I've been seeing this rejection a lot more lately. Anyone know what the correct answers are to the questions so we can bill it under part D?

Does member live in assisted care facility?
Does member live at home?
Does member have asthma or COPD?

 

[Jibby321]

I've been seeing this rejection a lot more lately. Anyone know what the correct answers are to the questions so we can bill it under part D?

Does member live in assisted care facility?
Does member live at home?
Does member have asthma or COPD?

If it's anything for me uglier I believe it has to be under B. The majority of claims I have seen for albuterol solution if they have Medicare has been through B.

 

[Wheresmyaricept]

Med D won't cover it if it's for a chronic diagnosis. I've called on this before and a pharmacist (and only a pharmacist) needs to call and give the diagnosis code (which we usually don't have). If it's not for chronic use they'll cover it.

Or just call the doctor and switch it to the inhaler instead of nebulizing solution so it gets covered no questions asked.

 

[Ackj]

I've been seeing this rejection a lot more lately. Anyone know what the correct answers are to the questions so we can bill it under part D?

Does member live in assisted care facility?
Does member live at home?
Does member have asthma or COPD?

I would assume "No, yes, No" would get it covered under D, because that would imply it's a regular ambulatory patient who is using it temporarily, like for bronchitis or pneumonia. Any other combination of answers I believe makes it fall under B.

 

[PharmdA07]

We always bill it through part B and please make sure you're reimbursed enough to make a profit (sometimes the plan does not pay the pharmacy enough) and also make sure you have all the paperwork ready in case of an audit. If they have medicaid, sometimes it can be used as a secondary for a COB claim that may defray their copays

 

[Lnsean]

We always bill it through part B and please make sure you're reimbursed enough to make a profit (sometimes the plan does not pay the pharmacy enough) and also make sure you have all the paperwork ready in case of an audit. If they have medicaid, sometimes it can be used as a secondary for a COB claim that may defray their copays

You cannot always bill part B. It depends on the diagnosis. You're going to get chargebacks for improper diagnosis and documentations (yes the doctor will have to fill out an order form as well). Like many posters here have said, chronic dx (asthma, COPD) should be going through part B whereas acute dx (bronchitis, pneumonia, SOB) should be going through part D. I know part D will auto reject and I have seen many rphs at my company just randomly push it through part B just to get the claim to go through and then we get a bunch of chargebacks months later. At Walgreens, when you try to bill part B, the system prompts you to verify all of these and then put in an override. Of course, people don't care and they just override it anyway just to get the customer and claim out of the way and then we take a hit on these months later. Albuterol is cheaper but when you're doing this on Brovanna and other brand meds...you're looking at thousands of dollars in chargebacks. Please don't do this.

 

[rxmommy7]

I have never gotten treatments for an acute diagnosis go through part D for a patient at home. Do you call the insurance company for an override, or are you at the mercy of the dr waiting for a PA?

 

[Sparda29]

That's the thing, I don't want to bill it to Part B. I just want to bill it to their Caremark Part D plan and be done with it. Doctor doesn't want to change it to inhaler. I don't have the info to bill it to Part B anyway.

So just tell insurance rep that it's something acute and it should go through Part D correct?

 

[PharmdA07]

You cannot always bill part B. It depends on the diagnosis. You're going to get chargebacks for improper diagnosis and documentations (yes the doctor will have to fill out an order form as well). Like many posters here have said, chronic dx (asthma, COPD) should be going through part B whereas acute dx (bronchitis, pneumonia, SOB) should be going through part D. I know part D will auto reject and I have seen many rphs at my company just randomly push it through part B just to get the claim to go through and then we get a bunch of chargebacks months later. At Walgreens, when you try to bill part B, the system prompts you to verify all of these and then put in an override. Of course, people don't care and they just override it anyway just to get the customer and claim out of the way and then we take a hit on these months later. Albuterol is cheaper but when you're doing this on Brovanna and other brand meds...you're looking at thousands of dollars in chargebacks. Please don't do this.

Yes I know about the charge-back (it's a mess and a huge loss for pricey drugs like brovana or Peformorist). We did take a hit of that in the past and after that our manager went and talked with all the docs in town whom we filled for most often with these meds and since then all the Rx I've seen are all for chronic conditions (and indeed these patients are chronic sufferers of COPD, Asthma, Emphysema, etc. ). For acute Rx, yes I did call insurance for couple of times and was asked about Dx code like people on here said but it was a hit-and-miss. I did get 1 claim to go through for albuterol, and I remember another one for atrovent neb part D asked for P.A.--which is another code word for "good luck waiting!" LOL