Wiki Drug Reimbursement from Medicare Advantage Plans

[aknoper]

Hello!
I'm sure (hoping) there is an easy answer to this but I cannot find it and when I call the payers they are no help. When I bill for a provider injection and the provider is using drugs from their stock we bill two codes; one for the injection and one for the drug. For example; A vitamin B injection is billed out as 96372 for the injection and J3420 for the drug. If I bill these two codes for a patient that has Traditional Medicare, Medicare pays on both codes just fine but if the patient has a Medicare Advantage plan they ALWAYS deny the drug code (J3420) and state that the code is covered by another payer even when the patient has a drug plan through that payer. It happens with all Medicare Advantage plans and I cannot figure out why they won't pay if Medicare pays just fine. Any ideas?

 

[Cbaxter001]

Howdy!
With that type of denial I would try and call the payer to see if they can release more information to you, but there are a few things that could be happening. The drug may not be on the plan level formulary, there also might be a coverage restriction that you have to meet before coverage is active for the drug, and check and see if the patient has to use an in network pharmacy and bring the injectable into the office and your doctor would just perform the injection (96372).