State Medicaid programs pay for covered outpatient drugs and vaccines through several claim types. Program expenditures billed through institutional outpatient claims and professional medical claims are substantial. The correct submission of pharmaceuticals on these claim types by using HCPCS procedure codes is often an area of confusion for medical providers, which commonly results in billing errors, overpayments and rebate disputes. Based upon Myers and Stauffer’s extensive experience in reviewing medical claims to identify incorrect payments, we have identified several common categories of billing errors where Myers and Stauffer can assist your state Medicaid program in payment error identification and recovery:

Utilizing incorrect billing unit increments
Occurs due to a misunderstanding of how to appropriately bill for the drug by incorrectly submitting the total number of milligram (mg) or milliliters (ml) administered as the quantity used, instead of submitting the billing unit increments that are represented by a specific HCPCS code.

Billing for unused portions of a multi-dose packaged drug
Occurs when a provider administers a drug that is packaged in a multi-dose vial. The provider incorrectly submits a quantity representing the entire contents of the vial, instead of just the partial contents of the multi-dose vial that was actually administered.

Submitting incorrect quantities
Occurs when there is a clerical error in entering the correct quantity used, and the resulting amount billed is above what has been determined to be a reasonable maximum allowable amount for that drug.

Not utilizing dose consolidation to achieve the necessary dose
Occurs when the drug is available in various strengths which are multiples of one another, and providers did not submit the most dose-efficient strength of the medication for reimbursement.

Not billing at 340B acquisition cost when required by the Medicaid program
Occurs when the billed amount on a claim does not represent the provider’s 340B acquisition cost. Myers and Stauffer utilizes several claim elements and pricing benchmarks to determine if 340B acquisition costs are being submitted. Myers and Stauffer can also utilize state supplied rebate information for analyzing 340B acquisition cost billing.

Based upon recent state Medicaid experience, programs can anticipate a positive return on investment for procedure coded drug claim review expenditures.

For More Information
We encourage you to contact Lynsey Plew by email at to arrange a discussion or meeting for more information regarding our Procedure Coded Drug Claims Program.


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