10 Common Blunders of Pharmacy Billing

Pharmacy Medical billing errors are prevalent in practices and can be easily made. But, they do have repercussions on the overall profit of a healthcare organization. The American Medical Association states that errors in medical coding fall under the broad category of fraud and abuse. So said, the former means “intentional misrepresentation” and later is “the falsification was an innocent mistake.”

Medical coding and pharmacy billing are complicated processes that depend on the patient, insurer, and procedures. Even the most honest financial departments experience claim denials. But knowing these blunders beforehand can help you take steps to avoid them.

Here are the ten most common blunders in pharmacy billing. 

  1. Invalid prescription

Pharmacy benefit managers have access to your prescription claims to identify the claims that don’t meet legal regulatory or industry-established standards. One of the top reasons where pharmacy claims are denied is an invalid prescription. 

Federal and state decide what constitutes a valid prescription. E.g., an invalid medication will be if there is a missing prescriber’s signature, drug quantity, dates, or missing patient information.

  • Incorrect prescription refills

If there were some blunders on managing supply on the previous fill, it could lead to a prescription refilled sooner than average regulated amounts, which is an immediate warning sign. 

  • Incorrect NPI to DEA number

A prescription must match NPI and DEA as a prescriber identification number on the claim. 

  • Incorrect quantity of a supply

Days of supply and number of refills are also essential factors for submitting the correct quantity. Errors happen when pharmacists fail to be vigilant on the prescribed dosages, which can cause massive pharmacy billing blunder causing claim denials.

  • Incorrect supply management

For pharmacies, it is tough to calculate days of supply, specifically if the prescription has a complicated dosing routine. As a result, blunders commonly happen while entering the proper claim for ophthalmic/otic, inhaled, vaginal, and topical products, as it is hard to pin down the right amount of dose or supply.

  • Incorrect procedure codes

If you are receiving claims back more frequently, there might be an incorrect input of codes. A mistyping blunder can cause to have the wrong code in the system. It can also happen if a document is incorrectly coded and submitted to the medical billing department.

There is also a slight chance of human error where a staff member doesn’t follow the correct coding procedure. In such cases, it is crucial to provide necessary training to the staff to avoid such blunders. 

  • A claim is missing information.

The most common missing factors that cause denials are a)date of a medical emergency, b)date of the accident, and c) onset date. Therefore, it is crucial to check for these missing fields with proper documentation.

  • Upcoding

Upcoding occurs when patients are being billed for more procedures than they receive. It can also happen when medical bills are submitted for the procedures that weren’t done in the first place.

Upcoding also happens if the medical billing department makes a mistake when entering wrong treatment codes or a physician fails to provide accurate information.

  • Claim not filed on time

If a claim is not filed within a given period, it might result in a denial. Therefore, healthcare providers and medical billing services should be aware that they must submit the claims within 12 months of duration.

  1. Mishandled payments

One of the common errors in medical billing is when the payer has over or underpaid, leading to claim denial. Either the case, should rectify this error quickly and should process interest payments correctly.

Conclusion: To ensure your practice has long-lasting success, you have to optimize your billing efforts. It is essential to eliminate the most common medical billing mistakes and develop strategies to prevent them from impacting your revenue cycle. 

One of the best methods to remove such blunders is to outsource medical billing services. At 24/7 Medical Billing Services, we help practices increase their revenues by reducing claim denial rates. Learn more from our experts; book a free consultation today!

Read More : Why Outsource Pharmacy Billing Services?

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