After submitting a claim from the pharmacy, it will then hit a service that routes the claims to the proper insurance company or PBM based on the identifiers. These are known as ‘switches’; examples of companies that offer switching services include RelayHealth and Emdeon. Switches usually charge a fee for every transaction, although they might […]

The most common categories of commercial payers to be aware of are employer-sponsored health plans and manufacturer vouchers. In the case of the patient with commercial coverage, by law, it is billed before Medicaid and Tricare and is almost always the primary payer. A common misunderstanding among patients with manufacturer vouchers (i.e. ‘co-pay cards’) is […]

Payers audit pharmacies because of billing history, a referral from an FWA hotline, a routine, random audit, or other reasons that might signify a potential for FWA to the payer. Often it is in the form of a desk audit, where the pharmacy will be required to fax documentation back to the payer, but can […]