Are you looking to improve your bottom line. Here are a few items that we have found that affects a pharmacies reimbursement.
DAWs – If the DAW is not the appropriate code on a claim can cause a lower reimbursement. QRx is able to review the DAWs on claims with our edits. The reason for this is that a more appropriate DAW should be submitted with the claim which will improve reimbursement and reduce audit exposure for improperly selecting brand drugs over the cheaper generics. If a pharmacy changes the drug or assigns a more appropriate DAW the claim we provide it on easy to read report.
Paid at Usual and Customary – Are you getting paid appropriately or are you not billing for the appropriate amount? QRx is able to review when a claim is submitted U&C is equal to Total Reimbursement that is “red flagged” and should be reviewed for possible reversal and resubmission by pharmacy. Often these claims are related to timeliness of Pharmacy System AWP updates, but when U&C is not AWP based, other pricing structure elements should be reviewed. Other common factors affecting low U&C could be obsolete NDC’s set/hard coded NDC pricing, or quantity/package issue. QRx is able to identify them with ease and provide the pharmacy with a weekly report so the pharmacy can respond timely with rebilling pharmacy protocols.
Negative Reimbursement – Are your receiving MAC pricing? QRx is able to capture claims that have a Zero reimbursement. We assist our clients with identifying these claims and payers. Allowing the pharmacy to review their processes and improving reimbursement and efficiency.
Let us help you with starting the New Year with improving your pharmacy’s reimbursement and lowering your audit exposure.
Contact Angie at 706-400-0738 for more information or Demo.
This post is related to:
Finance: Worker's Comp, Claims, PA Management, Adjudication
