Proair daily supply

[mona2004]

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If a rx was written for proair #2 one for school one for home sig ;2 puffs Q4 hr
Can we bill insurance for.2 units with daily supply 30 or should only bill one with daily supply 16?

 

[WVUPharm2007]

If the physicians said to dispense two, then you dispense two and make it a 33 day supply if possible or a 30 day supply if that's what's required by the insurance.

 

[pharmalt82]

If the physicians said to dispense two, then you dispense two and make it a 33 day supply if possible or a 30 day supply if that's what's required by the insurance.

I think it defers by insurance company. We need to make phone calls to caremark, aetna, cigna, etc. to figure this out.

Anyone have phone numbers?

 

[BidingMyTime]

If a rx was written for proair #2 one for school one for home sig ;2 puffs Q4 hr
Can we bill insurance for.2 units with daily supply 30 or should only bill one with daily supply 16?

You would have to bill for a 32 day supply, if the insurance limits to a 30 day supply, then you could only bill 1 for 16 days....the pt could pay cash for the 2nd one, or come back in 16 days to get a refill.

If the physicians said to dispense two, then you dispense two and make it a 33 day supply if possible or a 30 day supply if that's what's required by the insurance.

That's insurance fraud. Changing the days supply to get it to go through insurance is fraud. If the insurance limits to a 30 day supply or less, than only 1 inhaler can be given. The insurance company doesn't care what a doctor writes for, they aren't going to pay for an RX that doesn't meet their guidelines.

 

[BenJammin]

Really? You guys are confused about this? Insurance will only pay for a 30 day supply so if one ProAir lasts 16 days then you can only dispense one inhaler.

 

[zelman]

...That's insurance fraud. Changing the days supply to get it to go through insurance is fraud. If the insurance limits to a 30 day supply or less, than only 1 inhaler can be given. The insurance company doesn't care what a doctor writes for, they aren't going to pay for an RX that doesn't meet their guidelines.

I agree. However, I have been told point blank by insurance companies' helpdesks to do it. It might be worth a call to document their request that you do so.

 

[FarmD711]

So what about something like Premarin cream? That lasts much longer than 30 days with most typical directions.


Are we supposed to squirt a few grams from the tube into an ointment jar to make a 30 days supply? Tell the patient the medication is not covered? Or just bill for 30 days for a full tube?

 

[owlegrad]

You would have to bill for a 32 day supply, if the insurance limits to a 30 day supply, then you could only bill 1 for 16 days....the pt could pay cash for the 2nd one, or come back in 16 days to get a refill.



That's insurance fraud. Changing the days supply to get it to go through insurance is fraud. If the insurance limits to a 30 day supply or less, than only 1 inhaler can be given. The insurance company doesn't care what a doctor writes for, they aren't going to pay for an RX that doesn't meet their guidelines.

What do you do for test strips? Or anything that comes in a >30 ds package size?

 

[BidingMyTime]

What do you do for test strips? Or anything that comes in a >30 ds package size?

So what about something like Premarin cream? That lasts much longer than 30 days with most typical directions.
Are we supposed to squirt a few grams from the tube into an ointment jar to make a 30 days supply? Tell the patient the medication is not covered? Or just bill for 30 days for a full tube?

I would document on the hard copy that the medication is only available in an unbreakable package size, and then run it for the maximum days supply the insurance will allow. For a patient testing QD, I wouldn't give a box of 50 strips for a 30 day supply, when there is a box of 25 strips available. But if the smallest package size is 50 strips, then I would run that for 30 days, after documenting. Same with Premarin cream, run it for 30 days (or 90 days if their insurance allows) & document that the package can not be broken.
I would document on the hard copy that the medication is only available in an unbreakable package size, and then run it for the maximum days supply the insurance will allow. For a patient testing QD, I wouldn't give a box of 50 strips for a 30 day supply, when there is a box of 25 strips available. But if the smallest package size is 50 strips, then I would run that for 30 days, after documenting. The key to legality is giving the smallest available package size, giving 2 Proairs would not meet that criteria.

 

[BidingMyTime]

I agree. However, I have been told point blank by insurance companies' helpdesks to do it. It might be worth a call to document their request that you do so.

Yeah, I worked at a store that got a charge-back for that, even though the name of the company representative who told them to do this was documented. I quickly learned not to believe representatives when they told me to do illegal things.

 

[owlegrad]

I would document on the hard copy that the medication is only available in an unbreakable package size, and then run it for the maximum days supply the insurance will allow. For a patient testing QD, I wouldn't give a box of 50 strips for a 30 day supply, when there is a box of 25 strips available. But if the smallest package size is 50 strips, then I would run that for 30 days, after documenting. Same with Premarin cream, run it for 30 days (or 90 days if their insurance allows) & document that the package can not be broken.
I would document on the hard copy that the medication is only available in an unbreakable package size, and then run it for the maximum days supply the insurance will allow. For a patient testing QD, I wouldn't give a box of 50 strips for a 30 day supply, when there is a box of 25 strips available. But if the smallest package size is 50 strips, then I would run that for 30 days, after documenting. The key to legality is giving the smallest available package size, giving 2 Proairs would not meet that criteria.

You say 'I would' like this has never happened to you, lol.

 

[BidingMyTime]

You say 'I would' like this has never happened to you, lol.

Mom, is that you? 😕

 

[kvl1027]

You would have to bill for a 32 day supply, if the insurance limits to a 30 day supply, then you could only bill 1 for 16 days....the pt could pay cash for the 2nd one, or come back in 16 days to get a refill.



That's insurance fraud. Changing the days supply to get it to go through insurance is fraud. If the insurance limits to a 30 day supply or less, than only 1 inhaler can be given. The insurance company doesn't care what a doctor writes for, they aren't going to pay for an RX that doesn't meet their guidelines.

Fraud is a bit of a stretch. If the physician has documented on the Rx that the patient and you have noted on the rx that the pt requires two separate inhalers, one for home and one for school, and the medication is in an unbreakable package you can dispense 2 for 30 days.

I work for an independent pharmacy and we get audited all the time. We have be burned on claims before, but never had funds recouped for this. I spoke with an auditor about this exact subject and this practice is acceptable.