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Drug Reimbursement

  1. #1
    Unhappy Drug Reimbursement
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    I have been tasked with an analysis on insurance reimbursements for injectable drugs given at our Primary Care office.
    I knew there were a lot that were being reimbursed below cost, but I cannot believe how bad it actually is! We are losing so much money it is ridiculous.
    What concerns me is that in most cases, 4 out of the 5 insurance payors analyzed are reimbursing below cost. How could they all be such crappy payers? I have been trying to no avail to find some list of the ASP for these drugs so I can get to the bottom of where the real problem is. The CDC posts a list of the private sector costs per dose of vaccines and that was very helpful for me in the past when I did vaccine analysis, but now I am stumped on the drugs......

    Our worst discrepancies are with:
    J1080 - Testosterone
    J7321 - Hyalgan
    J2920 - Solumedrol

    Does anyone out there have any insight as to how I might be able to get the information I need? Does anyone have similar experiences?

    I thank you in advance for any advice/info.
    Have a splendiferous day!

  2. #2
    Jacksonville River City AAPC
    Default Look at CMS
    The CMS website ( publishes the ASP on a quarterly basis.

    You may want to check that you are billing the correct number of units for the drug administered according to the description - make sure you aren't losing due to improper conversions.

    Also, if there is a generic form available and your company purchases brands, that could skew the reimbursement as most payers will set their allowable based on the ASP for the generic form.

    The undertaking is no small task and I understand the pain you are going through. I've been involved in a similar project and it is enough to make your head spin!
    Melissa Caperton, RHIA, CPC, CPMA, CPPM, CFPC, Approved Instructor
    Past Chair AAPC Chapter Association Board of Dirctors
    Past-President, River City AAPC
    Executive Co-Chair, Coding on the River

  3. #3
    Default Thanks!
    Thanks so much Melissa. I will check into what you noted.
    All the best,

  4. #4
    Bay City, MI
    Medical Billing
    I work for an insurance company that pays for medical treatment of worker's compensation and PIP auto injuries. Payment for any drugs is based on the NDC number, units, and Red Book prices. We try very hard to be fair in our reimbursements and are willing to review each request for reconsideration.

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