With the cost of drugs soaring, and American's under changing insurance regulations, it is not surprising that drugs are one of the highest analyzed billed charge. Both Medicare and Medi-Caid conduct what they call manual Drug Reviews. So what it is?
Well, essentially they will pick one drug (typically a high dollar drug with a high dollar reimbursement) and review the claims to make sure that the drug is medically necessary. With cancer running rampant these days, and no definitive cure, the research drugs carry a high price tag. These high dollar drugs also have been proven to be effective under certain circumstances or with specific diagnoses.
If asked for medical record back up for this kind of query, make sure to include the patient's diagnosis, dosage regimen, chart notes, and reports showing efficacy of the drug. Often times they will also ask for the invoices to see exactly what was paid for the drug. And, with the case of Medicare and Medi-Cal, these charges are paid on the number of units billed, rather than the total cost of the drug.
All this to say, be prepared. These types of inquiries are regular and important.
Until next time:
Have this blog delivered straight to your Kindle!
Reach me on Twitter @LorettaLea
#medbill #health #insurance
Author, Medical Billing, Coding, and Reimbursement
A medical billing professional for over 30 years now, I have seen a lot of changes in this field, and there are a lot more on the horizon. Follow me as we see what they mean and for who.