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I hate split-billing NY Medicaid. (Epic, very technical)
This probably won't make a whole lot of sense to anyone but pharmacy personnel, but I know there are a few of you out there, and I gotta rant to someone or I'm gonna plotz.
BG: Up until last October, we billed Medicaid directly for prescriptions. Starting then, everyone got placed in an HMO, and we now bill them, or rather, their third-party processor. Most of the folks around here took Fidelis, who use Advance-Rx (a.k.a. CVS/Caremark) for their processing, and their stuff comes through either with no copay, or a nominal copay (like $1.00).
There were a few, though, who opted for some other HMO that processes through Medco; these families have a normal copay, which could be anything from $5.00 to $15.00 to $55.00 or whatever, and the copay then gets billed to Medicaid like we used to do.
In order to do this split billing, as it's called, there are hoops to jump through. On the secondary claim, we have to put in a COB code (coordination of benefits), which differs depending on what the primary pays.
* IF they pay something and leave a copay, then it's 02 (Other Insurance, Payment Collected).
* IF they pay NOTHING and leave a copay, then it's 04 (Other Insurance, Payment Not Collected).
* IF they reject it altogether, then it's 03 (Other Insurance, Claim Not Covered).
The problem is, until the primary claim goes through, you have no way of knowing what to put on the COB for the secondary. So you guess, based on what the stuff costs, what you think his copay is gonna be, etc. Often you guess wrong. This means you wind up sending each claim through multiple times (at 13c per transmission, of course).
Not that our software makes it easy. [ASR motto: All Software Sucks] To even get to the COB screen, you have to pull up the RX details, click Claim Info, then select the secondary in the drop-down menu. Then you first get to select the COB code from more drop-down menus. You also have to select the ID qualifier from yet another drop-down menu, which is always 03-RXBIN, then input 610014 (which is the RXBIN for Medco) in the box. Save, save, X out of the print dialog (because if you hit that, it'll rebill the primary, which you don't want to do,) then Cancel, go back to the CAM screen, select the secondary claim and click on Resubmit. If there's a short cut for any of that, I don't know it. (End b/g)
So. Local doctor e-prescribes two prescriptions. One for Bactroban cream (antibiotic), and one for Mycolog-II (combination antifungal/anti-inflammatory). He wants us to mix them together so the patient can apply them together. Ordinarily we'd submit this as a compound prescription, so we get paid for my labor in putting the stuff together and not just the cost of the ingredients. Problem is Medicaid fee-for-service is almost impossible to submit a compound to and still get paid, and it's done differently from the other insurances (quantity dispensed is always 1 regardless of what you dispense), so you can't split bill a compound at all that I know of. So in this case, I'll submit it as two separate prescriptions, meaning we don't get any compounding fee, but it's five minutes labor to mix two creams together, so it's not like we're losing that much.
First I put in the Mycolog. Bill for 30 grams. Primary pays, secondary rejects. Why? Got the COB wrong. I put 04, they want 02. Jump through hoops (see above), retransmit, it goes through. Boruch Hashem (praise the Lord).
Then put in the Bactroban. 30 grams again, because it's supposed to be 1:1. Primary rejects. Why? Plan limitations exceeded. They'll only pay for 15 grams.
Fine, I can change that, BUT I now have to go back and change the first prescription to 15 grams to match, because we need even amounts of both.
So. Go back and reverse the first prescription. Then change the second prescription to 15 grams. Primary pays, secondary rejects. Why? Wrong COB. I put 02, they wanted 03 (because they passed the whole retail price through as the copay, which means they didn't cover it. If there had ben a normal $15 copay, then 02 would have been correct).
Change the COB code (hoops, etc.) to 03. Resubmit. Secondary rejects. WHY?? Quantity mismatch. Seems that this tube is flagged in the system as a 30 gram tube, so you can't bill for anything but multiples of 30.
Grrr.
Try to change NDC to reflect the 15 gram tube. Discover that there's apparently no way to change the NDC on a prescription that's already been entered. (Not true, as I later figured out how to do it while working on another prescription. Maybe there's some esoteric reason it didn't work in this case, I dunno.)
Delete that prescription altogether, reenter it with the correct NDC, put in the right COB (hoops, etc.) Rx goes through the first time. Praise the Lord. Woohoo, etc.
Go back to the first prescription. Change quantity to 15. Send it through. Primary pays, secondary rejects. WHY??!? You guessed it, wrong COB again. I'd figured that for the 15 grams of Mycolog, the copay would have been all we'd gotten from them, so I put 04, but it turns out they actually sent us a whole twenty two cents, which means 02 is correct. Change that (hoops, etc.) Resubmit, and finally get paid for this damn prescription.
You wanna know how much we got paid for all this farting around? For the 15 grams of Mycolog, we got $4.74 from Medicaid and $0.22 from Medco, for a grand total of $4.96. My cost for this product is $15.06. This means we took a net loss of $10.10 on it (for which my boss is probably gonna rip me a new one next time I come in, and deservedly so). For the Bactroban, we got diddly-squat from Medco and $55.39 from Medicaid, for a product that costs me $50.54. The net profit of $4.85 does not offset the loss on the other ingredient. Not to mention that the jar I put it in cost us 98 cents. And just for the hell of it, go back and count those transmissions, at 13 cents apiece; split bills count as two, so that's 26 cents each time. Even without the loss on the Mycolog (which recently hextupled in price, for the same reason that the dog licks his balls: because they can.), all those transmission fees would have eaten up any profit we might have made.
So if you wonder why the independent pharmacies are closing down one after the other, look no farther.
Next time I get one of these, I'm sending the patient to Aide of Right. Bugger this for a game of soldiers.
BG: Up until last October, we billed Medicaid directly for prescriptions. Starting then, everyone got placed in an HMO, and we now bill them, or rather, their third-party processor. Most of the folks around here took Fidelis, who use Advance-Rx (a.k.a. CVS/Caremark) for their processing, and their stuff comes through either with no copay, or a nominal copay (like $1.00).
There were a few, though, who opted for some other HMO that processes through Medco; these families have a normal copay, which could be anything from $5.00 to $15.00 to $55.00 or whatever, and the copay then gets billed to Medicaid like we used to do.
In order to do this split billing, as it's called, there are hoops to jump through. On the secondary claim, we have to put in a COB code (coordination of benefits), which differs depending on what the primary pays.
* IF they pay something and leave a copay, then it's 02 (Other Insurance, Payment Collected).
* IF they pay NOTHING and leave a copay, then it's 04 (Other Insurance, Payment Not Collected).
* IF they reject it altogether, then it's 03 (Other Insurance, Claim Not Covered).
The problem is, until the primary claim goes through, you have no way of knowing what to put on the COB for the secondary. So you guess, based on what the stuff costs, what you think his copay is gonna be, etc. Often you guess wrong. This means you wind up sending each claim through multiple times (at 13c per transmission, of course).
Not that our software makes it easy. [ASR motto: All Software Sucks] To even get to the COB screen, you have to pull up the RX details, click Claim Info, then select the secondary in the drop-down menu. Then you first get to select the COB code from more drop-down menus. You also have to select the ID qualifier from yet another drop-down menu, which is always 03-RXBIN, then input 610014 (which is the RXBIN for Medco) in the box. Save, save, X out of the print dialog (because if you hit that, it'll rebill the primary, which you don't want to do,) then Cancel, go back to the CAM screen, select the secondary claim and click on Resubmit. If there's a short cut for any of that, I don't know it. (End b/g)
So. Local doctor e-prescribes two prescriptions. One for Bactroban cream (antibiotic), and one for Mycolog-II (combination antifungal/anti-inflammatory). He wants us to mix them together so the patient can apply them together. Ordinarily we'd submit this as a compound prescription, so we get paid for my labor in putting the stuff together and not just the cost of the ingredients. Problem is Medicaid fee-for-service is almost impossible to submit a compound to and still get paid, and it's done differently from the other insurances (quantity dispensed is always 1 regardless of what you dispense), so you can't split bill a compound at all that I know of. So in this case, I'll submit it as two separate prescriptions, meaning we don't get any compounding fee, but it's five minutes labor to mix two creams together, so it's not like we're losing that much.
First I put in the Mycolog. Bill for 30 grams. Primary pays, secondary rejects. Why? Got the COB wrong. I put 04, they want 02. Jump through hoops (see above), retransmit, it goes through. Boruch Hashem (praise the Lord).
Then put in the Bactroban. 30 grams again, because it's supposed to be 1:1. Primary rejects. Why? Plan limitations exceeded. They'll only pay for 15 grams.
Fine, I can change that, BUT I now have to go back and change the first prescription to 15 grams to match, because we need even amounts of both.
So. Go back and reverse the first prescription. Then change the second prescription to 15 grams. Primary pays, secondary rejects. Why? Wrong COB. I put 02, they wanted 03 (because they passed the whole retail price through as the copay, which means they didn't cover it. If there had ben a normal $15 copay, then 02 would have been correct).
Change the COB code (hoops, etc.) to 03. Resubmit. Secondary rejects. WHY?? Quantity mismatch. Seems that this tube is flagged in the system as a 30 gram tube, so you can't bill for anything but multiples of 30.
Grrr.
Try to change NDC to reflect the 15 gram tube. Discover that there's apparently no way to change the NDC on a prescription that's already been entered. (Not true, as I later figured out how to do it while working on another prescription. Maybe there's some esoteric reason it didn't work in this case, I dunno.)
Delete that prescription altogether, reenter it with the correct NDC, put in the right COB (hoops, etc.) Rx goes through the first time. Praise the Lord. Woohoo, etc.
Go back to the first prescription. Change quantity to 15. Send it through. Primary pays, secondary rejects. WHY??!? You guessed it, wrong COB again. I'd figured that for the 15 grams of Mycolog, the copay would have been all we'd gotten from them, so I put 04, but it turns out they actually sent us a whole twenty two cents, which means 02 is correct. Change that (hoops, etc.) Resubmit, and finally get paid for this damn prescription.
You wanna know how much we got paid for all this farting around? For the 15 grams of Mycolog, we got $4.74 from Medicaid and $0.22 from Medco, for a grand total of $4.96. My cost for this product is $15.06. This means we took a net loss of $10.10 on it (for which my boss is probably gonna rip me a new one next time I come in, and deservedly so). For the Bactroban, we got diddly-squat from Medco and $55.39 from Medicaid, for a product that costs me $50.54. The net profit of $4.85 does not offset the loss on the other ingredient. Not to mention that the jar I put it in cost us 98 cents. And just for the hell of it, go back and count those transmissions, at 13 cents apiece; split bills count as two, so that's 26 cents each time. Even without the loss on the Mycolog (which recently hextupled in price, for the same reason that the dog licks his balls: because they can.), all those transmission fees would have eaten up any profit we might have made.
So if you wonder why the independent pharmacies are closing down one after the other, look no farther.
Next time I get one of these, I'm sending the patient to Aide of Right. Bugger this for a game of soldiers.
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