The vast majority of reimbursement issues (and the corresponding dollars) are associated with the Average Wholesale Price (AWP). Misconfigured file update settings or outdated data could mean sending an inaccurate AWP value during the prescription submission process, potentially resulting in lost revenue.
The AWP is the industry benchmark price for a drug. Manufacturers, wholesalers, pharmacy benefits managers (PBM), the government, and pharmacies use this value as the “standard” price for selling, purchasing, and billing for medications throughout the supply chain, from the factory to the patient. Typically, the average wholesale price is not the actual purchase price, but it is vital to ensure accuracy at every point within the buying, billing, and reimbursement process. Contracts negotiated between a pharmacy and PBMs frequently include reimbursements based on the AWP minus a set percentage. If the AWP increases on a drug, the reimbursement should increase as well. However, there are times that it does not happen. Below are several reasons why.
Update Your Dispensing Software Data
Accuracy in the dispensing software is crucial. Regular AWP price file updates are an important and automated way to keep your AWPs up to date and accurate. Many software systems offer daily, weekly, or monthly updates. If you are updating your dispensing software less than daily, be aware that there could be a gap between when the AWP was increased and when your software was updated. Any prescription billed during that gap could be reimbursed at the old AWP, which is typically a lower amount. Net-Rx’s EditRx service includes an AWP Verification report, which helps to identify claims submitted with outdated AWP values. With this report in hand, you can update the AWP and rebill those prescriptions to receive the maximum reimbursement.
Verify the PBM
Similar to dispensing software, the PBMs must also update the AWP file on their systems, which can result in the same gap between when the AWP was increased and when their system was updated. If the pharmacy is submitting a claim with the new AWP, the PBMs may still use the AWP that is currently in their system, which may be lower. Review your prescriptions to ensure you are reimbursed based on the last AWP at the time of fill. Net-Rx’s EditRx service includes the AWP Retro report, which will identify prescriptions with reimbursement rate changes that you can resubmit for proper payment.
New Year, New Price
While the manufacturers can change the AWP at any time, we see the largest number of AWP changes in January and June. Due to the many changes occurring during this time, staying vigilant in confirming you are using the correct AWP and you are reimbursed accurately can have a positive effect on your bottom line.
In summary, reimbursements hinge on the accuracy of the AWP. An incorrect AWP in the pharmacy’s dispensing software or the PBM’s system can result in lost revenue for the pharmacy which will likely continue with every fill until the AWP is updated.
Net-Rx’s EditRx is an enhanced claims editing service that uses proprietary analytics along with the support of a pharmacy reimbursement trained analyst to detect under-reimbursed claims. Your analyst will review the AWP Verification and Retro reports with you, and suggest best practice solutions to help you correct anomalies, prevent missed opportunities and recover lost revenue.
To learn more about Net-Rx’s suite of solutions, visit https://www.net-rx.com/Products/EditRx/. You may also contact us at, Sales@Net-Rx.com, or 1-866-336-3879.
This post is related to:Claims Processing & Reconciliation