Testing at Pharmacies…Which Billing and Revenue Updates can Enhance Billing?

Testing at Pharmacies

Effective 15th January 2022, people with a health plan can go online, or to a pharmacy or store to purchase an at-home over-the-counter COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. CMS is strongly incentivizing health plans and insurers to set up a network of convenient locations across the country such as pharmacies or retailers where people with private health coverage will be able to order online or walk in and pick up at-home over-the-counter COVID-19 tests for free, rather than going through the process of having to submit claims for reimbursement. Insurance carriers will reimburse at a rate of up to $12 per individual test (or the cost of the test, if less than $12). In this Blog Check out here about Testing at Pharmacies and reimbursement practices you can enhance the revenue cycle management and reap more profits.

Insurance Reimbursements in Testing at Pharmacies

If a plan or insurer sets up a network of convenient options such as pharmacies or retailers, including online retailers, in which individuals on their plans can get their tests’ cost covered upfront (at the point of sale), then it is permitted to limit the per test reimbursement amount for retailers outside of that network. Specifically, if a plan or insurer establishes this type of direct coverage option, then the plan or insurer is permitted to limit the reimbursement for tests purchased outside of their network to $12 per test (or the actual price of the test, if less). Many commercially available at-home tests run about $12 or less per test. If the plan or insurer does not set up a process through which individuals can obtain a test with no upfront costs, then the plan and insurer must reimburse the full cost of the test, even if the test costs more than $12. For example, if an individual buys a two-pack for $34, and the plan or insurer has not set up a system to cover costs upfront, then the plan or insurer would have to reimburse the $34 instead of $24.

Billing for Uninsured

People without insurance can also get a free at-home test from some community health centers. The Biden-Harris Administration is purchasing 500 million over-the-counter at-home tests to be distributed for free to all Americans who want them, with the initial delivery starting in January 2022. There will be a website where Americans can request at-home tests for home delivery, for free. More information on this federal program is expected soon. In addition, the U.S. Department of Health and Human Services (HHS) is providing up to 50 million free, at-home tests to community health centers and Medicare-certified health clinics for distribution at no cost to patients and community members. As of December 21, 2021, all Health Resources and Services Administration (HRSA), supported health centers and Medicare-certified rural health clinics are eligible to participate in the program after completing the onboarding process. 

Buying More than One Test at a Time

The normal health plan will provide reimbursement for 8 tests per month for each individual on the plan, regardless of whether the tests are bought all at once or at separate times throughout the month. If a health plan has set up a network of convenient options such as pharmacies and retailers, in which individuals can get their tests’ cost covered upfront (at the point of sale) then the plan is permitted to limit the reimbursement for tests purchased outside of their network to $12 per test (or the actual price of the test, if less than $12). If more than one test is purchased or ordered at a time, such as a package with two tests in it, then the insurer would reimburse up to $12 for each of the tests purchased at that time.

Medicare Coverage

For people covered by original fee-for-service Medicare, Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests, with no beneficiary cost-sharing when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional. People with Medicare can access one lab performed test without cost-sharing per patient per year without an order. At this time original Medicare cannot pay for at-home tests through this program. Medicare Advantage plans may offer coverage and payment for at-home over-the-counter COVID-19 tests, so consumers covered by Medicare Advantage should check with their plan.

Medicaid and CHIP Programs Coverage

In accordance with the American Rescue Plan, State Medicaid and CHIP programs are required to cover FDA-authorized at-home COVID-19 tests. People with Medicaid or CHIP coverage should contact their state Medicaid or CHIP agency for information regarding the specifics of coverage for at-home COVID-19 tests, as coverage rules may vary by state.

MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle management services. If you are not sure about insurance reimbursements for the COVID-19 diagnostic test, then contact us. Our billing and coding experts are well versed with the latest pharmacy billing updates helping you to receive accurate insurance reimbursements. To know more about complete pharmacy billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226