Entering the new year means entering new patient insurance information into the system. While this process may feel tedious, it’s crucial to ensure accurate billing. It’s not a bad idea to scan new insurance cards to have on file and keep a close eye out for special patient specific ID numbers or person code(s).

While you’re taking the time to update the patient’s insurance, be sure to ask if any of their demographic information has changed. Do they have a new address? Did they learn of a new allergy, intolerance or sensitivity to a medication or ingredient? It is also important to include food allergies and any allergies to dyes or inactive ingredients such certain starch-based ingredients (e.g., starch derived from wheat) for those with Celiac Disease. Some additional examples include progesterone, which can contain peanut oils, and gelatin which is often used when making capsules. Some flu shots may not be appropriate for patients with egg allergies, and many medications have dyes in them to produce their coloring. Including patient allergies is critical for ensuring patient health and is also required by some PBMs. Section 10.08 of Caremark’s Provider Manual highlights this requirement for maintaining up to date Part D patient information on their profiles. Often during an on-site visit, Caremark auditors will ask to see a covered Part D patient’s profile, looking specifically for patient demographics and allergy information. While PAAS has not seen any significant recourse due to missing information on Part D patient profiles, consider validating these elements when updating insurance information. 

With the new year also comes new formularies. It is important to be extra cautious of any incoming refills that are utilizing a DAW 9, as a new formulary could require the generic version or even an alternative drug. PAAS suggests challenging any historical DAW 9’s by trying to bill the claim first with the generic. Historical use of DAW 9 should be challenged anytime there is a change in insurance, new prescription being authorized, or when a new generic or interchangeable biosimilar is approved in the marketplace

PAAS Tips:

• When a claim rejects due to a mismatch in the patient’s date of birth submitted on the claim (versus the date of birth on file with the insurance company), it is best to call the patient to verify the correct date of birth.
• If your system is correct and the insurance plan has documented the incorrect date of birth, have the patient contact their plan (or Human Resources Department for employee-sponsored plans) to update the information.
• When you see a blank field in the allergies section of a patient’s profile, be sure to confirm any allergy information with the patient and update their file accordingly. Rather than leaving the field blank for patients with no known allergies, be sure to document “no known drug allergies” to show it has been addressed
• If your system has “no known allergies” listed for a patient, periodically verify that this is still accurate, as some patients develop allergies and sensitivities to medications, ingredients and foods as they age.

By Trenton Thiede, PharmD, MBA, President at PAAS National^®, expert third party audit assistance, FWA/HIPAA and USP 800 compliance.