8.9 Resolving Claim Issues

There are times when a claim is approved online and the prescription is filled and picked up by the patient, but later the PBM refuses to pay the claim. The technician is often involved in resolving these “post-claim” functions: charge-backs and audits.

Charge-backs

A charge-back is a post-claim rejection of a prescription claim by a PBM or insurance provider that must be investigated and, if possible, resolved by the pharmacy technician. If the PBM representative feels that it has overpaid or paid something in error, it may charge back or deduct this amount from what it owes the pharmacy in reimbursement. A charge-back could occur for a number of reasons:

• The certificate of medical necessity for diabetes supplies was not completed properly (often missing a diagnostic code or frequency direction, as for blood sugar testing strips), or a signed renewal from the doctor was not obtained for a Medicare Part B claim.

• Online processing was not functioning due to an internet malfunction, and it was determined later that the patient was ineligible for drug insurance benefits.

• The primary insurer of a dual eligible patient was not billed or was billed second instead of first.

• A prescription was also filled at another pharmacy. (If this is the case, then the patient may need to be billed, and a flag put on his or her patient file to avoid repetition.)

In each case, to challenge or resolve the charge-back, the technician must verify the details of the original prescription and supplemental documentation, patient profile, and adjudication process. You must also find documentation on whether or not the patient actually received the prescription (by written or computer receipt) to figure out the inconsistences and perhaps fix the errors. If the charge-back is not resolved in a timely manner, then the pharmacy loses that money. If the prescription was dispensed several years ago, it may take hours to locate the prescription and resolve the issue to the PBM’s satisfaction.

Since investigating charge-backs is so time-consuming and potentially frustrating, it is important to make sure that you are very accurate in inputting the prescription and insurance information in the computer when processing the claims.

Medication Audits

If there are a number of charge-backs or unresolved claims, the PBM might initiate an audit, or a checking of the pharmacy’s prescription records to challenge problems (as is done by the IRS in a tax audit). These challenges can be from prescriptions that were processed three to six months earlier, or even two to three years ago. A community (or mail-order) pharmacy is also subject to periodic PBM medication audits. The audit challenge is commonly conducted via the mail, but occasionally a PBM representative will personally investigate past claims on-site. The technician may need to print out the prescription records of the patients listed on the audit.

Audits are intended to reduce fraud and waste. Correct billing and documentation of prescriptions are critical in overcoming the audit challenge. The following are examples of potential audit challenges:

• A patient was “not eligible” for prescription coverage on the date of the claim.

• The days’ supply of the tablets, capsules, ear drops/eye drops, or antibiotic suspension was entered incorrectly; for example, a prescription for the migraine drug sumatriptan (Imitrex) 100 mg #9 should be entered as a 30-day supply, not as a 9-day supply.

• Initials were missing from the pharmacist’s documentation of a phone prescription or from a transfer prescription; or the signature of the patient (or a representative) was missing.

• The pharmacy cannot prove the patient received the prescription. (The patient “attestation” signature is considered proof that the prescription was dispensed and must be present or sought out from the patient. Medicaid requires signatures on computer files or hard copies to be kept on file for audits.)

• On an “as directed” prescription, the frequency of the insulin dose or blood glucose check was not determined by a call to the prescriber’s office. Therefore, the days’ supply of medication might have been incorrect.

• Documentation was not provided on the original prescription of the reasons that a larger than normal quantity was dispensed.

• Problems occured with the DAW (dispense as written) designation. If a patient (not a prescriber) requests a brand name medication, then the order must be accompanied by DAW-2 (the patient is designated by the 2). If it is the prescriber who specifies “brand necessary,” the order must be entered as a DAW-1.

The pharmacy technician investigates the validity of these and other claim challenges and must resolve the issues within two weeks of receipt of the challenge. If the audit challenges are not resolved in a timely manner, then the pharmacy forfeits all reimbursement to those claims, resulting in a revenue loss.

Insurance Fraud

Challenges about false claims also need to be investigated and resolved. Filing a false claim is considered insurance fraud. It is subject to civil and criminal penalties if it is confirmed, as well as employment termination. For example, a pharmacy technician cannot dispense a medication to a patient and then post or bill the insurance three days later when the prescription refill is allowed. Instead, you must direct the patient to return in three days’ time to pick up the medication after the insurance approves it. If it is an emergency and the patient has (or will) run out of medication (lost, spilled, or on vacation) before the current prescription duration runs out, you may request an override from the PBM or the patient can pay cash for the medication.