Incorrect Billing - PDF

Document Sample
Incorrect Billing - PDF Powered By Docstoc
					                                   Alaska Medicaid
                                 Common Billing Errors

Alaska Medicaid performs periodic quality assurance reviews of paid pharmacy claims to evaluate the
accuracy of submitted claims information. Claims submitted with incorrect quantities or incorrect
billing units may result in overpayments that will be recouped by the Department. The following
examples are provided to assist you in determining the correct billing units for medications that are
commonly implicated in billing errors. Please also visit the National Council for Prescription Drug
Programs (NCPDP) website at http://www.ncpdp.org/standards_quic.aspx for additional information
regarding how billing units are determined and how to determine the correct billing units for a product.


Examples
Aranesp®
Claims should be submitted for the number of milliliters (mL) dispensed, not the number of syringes
dispensed.
The correct billing unit for one prefilled Aranesp 100mcg/0.5mL syringe = 0.5mL = 0.5 units.

Asmanex® Inhaler
Claims should be submitted for the number of grams dispensed, not the number of units or doses
delivered. The correct billing unit for one inhaler = 0.24 grams = 0.24 units.

Data Entry Errors
Data entry errors can occur with any medication and result in overpayments when an incorrect quantity
or NDC is entered on a claim.

Data entry errors are common with medications that have a decimal point in their billing units.
Examples: 8.5grams is entered as 85grams or 805grams.

Another common data entry error is the days supply is incorrectly entered in the quantity dispensed
field.
Example: 1 kit is dispensed for a 14 days supply but incorrectly billed as 14 kits dispensed for a 1 day
supply.

Selecting the incorrect NDC for the medication dispensed, despite the correct billing units being
entered on the claim, may result in overpayments or dispensing errors.
Example: a claim for #200 lancets is incorrectly submitted for #200 tablets of Fosamax because the
wrong NDC was selected.

Submitting claims with a prescriber ID other than the NPI number for the actual prescriber is a false
claim and can be recouped by the Department.



                                                                                             Page 1 of 4
Duac CS® Kit
Claims should be submitted for the number of kits dispensed (“each”), not the number of grams of gel
contained within the kit (45grams).

Enbrel® 50mg/mL prefilled syringe
Each syringe dispensed should be billed as the number of milliliters dispensed without rounding to the
nearest whole number. The correct billing unit for one syringe = 0.98mL = 0.98 units. The correct
billing units for one package of four prefilled syringes = 7.92mL = 7.92 units.

Enbrel® 25mg prefilled syringe and multiple-use vials
There are multiple Enbrel 25mg products available, each with a different billing unit; a single-use
prefilled syringe (NDC 58406045504) and a multiple-use vial (NDC 58406042534).

The prefilled syringe is billed as the number of milliliters dispensed. The correct billing unit for one
syringe = 0.51mL = 0.51 units.

The multiple-use vial is billed as the number of vials dispensed, or “each” vial. The correct billing unit
for one vial = 1 unit.

Influenza Immunization
Claims for the injectable seasonal influenza immunization should be billed as the number of milliliters
dispensed, not the number of injections provided or a rounded estimate of the number of milliliters
dispensed. The correct billing unit for one 0.5mL influenza immunization = 0.5mL = 0.5 units.

Lovenox®
Claims should be billed as the number of milliliters dispensed, not the number of syringes dispensed.

Lovenox® 30mg      = 0.3mL/syringe
Lovenox® 40mg      = 0.4mL/syringe
Lovenox® 60mg      = 0.6mL/syringe
Lovenox® 80mg      = 0.8mL/syringe
Lovenox® 100mg     = 1mL/syringe
Lovenox® 120mg     = 0.8mL/syringe
Lovenox® 150mg     = 1mL/syringe

Multi-Ingredient Compounds (MIC)
Compounds must be submitted with an NDC of “00000000000”, a compound code of “2”, the
appropriate dispensing unit form, the route of administration, the ingredient component count, the
product ID for each ingredient, the quantity of each ingredient, and the drug cost for each ingredient.

If one or more of the ingredients in the compound require a prescription for dispensing and are eligible
for coverage the compound will be covered.

If compound is eligible for coverage but one or more ingredients are non-covered or non-prescription
items, such as excipients, the ingredient(s) should be included in the compound product segments with
their corresponding quantity and price but the claim must also be submitted with an “8” in the
submission clarification code. Quantities of covered prescription ingredients should not be increased
to account for the quantities of non-prescription items in the compound.
                                                                                               Page 2 of 4
Claims submitted in any other manner, or with incorrect quantities of individual ingredients, may result
in overpayments that will be recouped by the Department.

PrevPac®
Claims should be submitted for the number of cards dispensed, not the sum of the number of tablets
and capsules dispensed. The correct billing unit for one card = 1 days = 1 unit.

ProAir® HFA Inhaler
Claims should be submitted for the number of grams dispensed. The correct billing unit for one
inhaler = 8.5 grams = 8.5 units. Claims submitted for 17grams are appropriate if the prescription is
written for two (2) inhalers and the days supply is entered correctly based on the prescriber’s directions
and the number of inhalations available. Claims submitted for the incorrect number of units or the
incorrect days supply will be recouped by the Department.

Caution: Ventolin® HFA is available in an 18 gram inhaler. If a claim is submitted for a ProAir®
inhaler with a quantity of 18 grams it may result in an overpayment that will be recouped.

Rebif®
Claims should be submitted for the number of milliliters dispensed, not the number of syringes.
The correct billing unit for one Rebif 44mcg/0.5mL syringe = 0.5 mL = 0.5 units.

Remicade®
Claims should be submitted for the number of vials dispensed (“each” vial), not the number of
milligrams or volume in milliliters following dilution dispensed. The correct billing unit for one vial =
1 unit.

Risperdal® Consta®
Claims should be submitted for the number of kits dispensed (“each” kit), not the volume of the
injection following reconstitution in milliliters. The correct billing unit for one kit (all strengths) = 1
unit.

Synagis® 50mg/0.5mL
Claims should be submitted for the number of milliliters dispensed, not the number of vials. The
correct billing unit for one vial = 0.5mL = 0.5 units.

Taxotere® 20mg/0.5mL and 80mg/2mL
Claims should be submitted for the number of milliliters dispensed before the first dilution of the
product. Each package contains a vial of docetaxel and a vial of diluents. The billing unit for each
package size is the volume of the undiluted docetaxel and not the volume of the docetaxel and the
diluents.

Correct:       The correct billing unit for one package of Taxotere 20mg/0.5mL = 0.5mL = 0.5 units.
Incorrect:     2mL or 2 units following the initial dilution.

Correct:       The correct billing unit for one package of Taxotere 80mg/2mL = 2mL = 2 units.
Incorrect:     8mL or 8 units following the initial dilution.



                                                                                                 Page 3 of 4
Vivitrol®
Claims should be submitted for the number of kits dispensed (“each”) not the volume of the
reconstituted injection. The correct billing unit for one kit = 1 injection = 1 unit.

Zmax®
Claims should be submitted for the number of doses dispensed (“each” dose) not the volume of the
reconstituted product or the number of grams dispensed. The correct billing unit for one dose = 1 bottle
= 1 unit.




                                                                                             Page 4 of 4

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:87
posted:4/14/2011
language:English
pages:4
Description: Incorrect Billing document sample