There are instances where pharmacies are submitting a claim to a commercial or government plan and, instead of sending a rejection to the pharmacy, the payer “flips” the transaction so that the response is from a cash discount card. This is being seen in claims that should be denied for:
• NDC Not Covered
• Coverage Terminated
This paid response from the payer includes the cash discount card information but this change in payer type is not apparent to the pharmacy.
• In turn, the pharmacy may receive a lower reimbursement from the cash discount card compared to that of a commercial or government plan, as well as be charged an administrative fee.
• The pharmacy is losing transparency into when coverage is terminated or a NDC is not covered; therefore, they cannot intervene to resolve.
• The pharmacy may attempt to complete a COB claim (to Tricare, Medicaid, etc.) thinking that the primary was paid by the commercial or government plan.
• Pharmacies often need NDC Not Covered rejections from Medicare in order to process claims under Medicaid instead (especially for OTCs).
• Potential negative impacts to other services a pharmacy has enabled (Price Check, Denial Conversion, and Continuity Of Care).
• Alerts pharmacy in real-time (by way of rejection message) that a cash discount card was used for reimbursement by the payer instead of the commercial or government plan the pharmacy submitted the claim to while simultaneously reversing the claim.
• Equips pharmacy staff with actionable messaging on next steps that should be taken according to the customer’s requirements.
• Enables pharmacy with transparency into reimbursement and patient awareness actions that can be performed before a prescription leaves the pharmacy.
• Reporting may offer helpful insight for payer negotiations.
Veridikal Technologies is a company focused on providing business analytic solutions for pharmacy and hospital business sectors. Our aim is to simplify the complexities of pharmacy data management. Veridikal offers Pre and Post Edits (PPE), Pharmacy Benefit Administration (PBA), and Medication Reconciliation solution sets designed to meet the unique needs of various classes of trade including hospitals and medical centers, university health systems, long-term care pharmacies, retail pharmacies, specialty pharmacies, hospices, correctional facilities, and employers/self-insured plans. Veridikal's advanced and informative pharmacy solutions are trusted and relied upon by all pharmacy classes of trade, pharmacy wholesalers, PSAO's, GPO's, industry advocacy, and regulatory groups.
This post is related to:
Finance: PSAOs, Revenue Cycle Management, Reconciliation Finance: Worker's Comp, Claims, PA Management, Adjudication Patient Care: Assistance Programs, Loyalty Resources, Discount Cards Practice Setting: Community / Retail Pharmacy Resources Practice Setting: Health System Pharmacy Resources Practice Setting: Long-Term Care Pharmacy Resources Practice Setting: Specialty Pharmacy Resources
