Pharmacy Billing – Blunders to Avoid


Medical billing errors are common and are a result of various discrepancies occurring while submitting claims. These errors can prove to be extremely costly to the practice. Same is the case with pharmacies that due to numerous errors end up leaving a lot of revenue on the table. Pharmacy billing get tedious to a larg e extent with billing requirements being different calling for experts in order to ensure smooth claim submission.

Errors in pharmacy billing are replete and it is better to be aware of the potential errors that take place in order to avoid them for a full reimbursement.

    • Errors are in the making when medications are dispensed by the pharmacies with no billing unit standard (BUS) from the NCPDP or have applied a non-conforming NCPDP billing unit for pharmacy transactions. These can cause difficulties during reimbursement adjudication.
    • Particularly common is the lack of awareness about BUS among start ups. Although their focus could be on developing and commercializing products, they are unaware of the established protocol for billing and payment process flow.
    • Despite diligence maintained by the database vendors, some products come in the market with no appropriate billing unit. At times, same products are listed under different billing units or it so happens that their billing unit is no longer applicable because the medication is reformulated or without informing. This ends up in pharmacists overcharging or being underpaid payors.
    • The biggest nightmare for pharmacists and payors is errors involving high volume prescriptions and medication kits. This is so because it requires a lot of time and manual intervention to correct them. Both sides have to investigate and adjust payment for each affected claim.
    • Dispenser confusion arising over whether to bill a product labeled as a kit as Each, Grams or MLs result into a billing errors covering kits, which are more complex to resolve.

Billing unit errors have had serious impact when there is an involvement of state Medicaid agencies, as overpayment or underpayment of rebates could possibly generate a fraud investigation by the state or CMS. Discrepancies in billing can prove highly disruptive and get time consuming to resolve issues. Hence an understanding of the plausible errors can help avoid