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Pharmacy bill format for organizations

Lisa Faast: All right, welcome back to another episode of becoming a pharmacy badass. And so many independent retail pharmacies billed for Medicare Part B, most of us do it because of insulin supplies. And so there's a lot happening there with the billers and the requirements and what Medicare is looking at. So we want to make sure you stay compliant. So we brought on, of course, the expert Jeff hedges, to help us dig into these different topics and help make sure that you are doing everything you're supposed to be doing. And that the billing company that you're using is doing everything that they're supposed to be doing, because we all just kind of assume our biller is going to help keep us compliant. But we can't just assume anymore, you you've got to really take responsibility and know what the requirements are. So if you're not familiar with Jeff, Jeff, go ahead and just give a brief overview. What you do with RJ hedges and how you help independent pharmacies and DME places keep compliance. Jeff Hedges: Thank you, Lisa. Yes, our company provides a proprietary software, super simple to use. It's written to the eighth grade levels. So all techs and clerks can understand it, because they're the ones normally getting the questions. So everything's online, you can buy our products, either in packages, and programs, or what are ala carte. So there's no hard fast way to order to order things because we offer all kinds of options. So we worked on what you need, not what you want. So, but anyways, everything's done, I all the documentation is required. We're talking about some of that here moment. But everything is kept up to date up to date, all the time. And DMEPOS products are the biggest changes that we work on on a daily basis. Lisa Faast: Yeah, and I think what really, you know, hangs most pharmacy owners up and this is something that I've learned over the years is that, you know, medical billing DME billing, you know, these other types of services that pharmacy provide, are really completely different types of businesses. I mean, they just have nothing to do with pharmacy, you know, they use hickspicks codes and not in DCs and, and with that change, and when once you step outside of pharmacy, you really are held to a whole different set of rules, you can't just assume what you do on the pharmacy side is Okay, on this side. So we're gonna dive into that DME side, and really explain what the differences are. And you know, how to make sure that you're doing what you need to be doing whenever dispensing on that DME side. So maybe just start us off on, you know, what, what are the things that pharmacies, you know, what are the first things that, you know, they got to be thinking about as they make that transition over to the DME side. Jeff Hedges: Okay, so when it comes to part B meds, and DME items, turn off your pharmacy had and forget everything, you know, because it doesn't apply. It's a whole different process. So when it comes to part B, we don't have a prescription, even though it looks like a prescription. It's called a standard written order. Again, we're back the Medicare, so it's always going to be complicated. So there's functions of that standard written order and a fairly simple I mean, all the requirements are there on ours is on our standard scripts we receive from our Doc's or through the script system. So at that point, now we got the standard written order. All the rules changed for DME on January 1 2022 and a half months before the pandemic started. And no one. Most people don't even realize that all that paperwork that you used to have to have has been eliminated. Which is, I mean, mind boggling. That Lisa Faast: point has never happened. It never goes that way. Jeff Hedges: Yeah, well, whenever all came out, I need to talk to a couple of credit aid buddies and they weren't getting it. And I finally showed him some of the documents, I said, this is all you need. And what you need is that standing written order, which is your normal prescription. Okay, at that point, you got to make sure that you got the product, the correct product, and you're dispensing it to the correct patient under the correct format. Yes, you can do it through your pharmacy software through these different billing companies out there that were working into your system. So we got contracted about billing, find out an easier way to do it. And one of the things we found that she was mind blowing because all of these audits are going on all the time. And I always look at how many the audits are being lost. And it's a And surely, these people aren't losing all these people are losing these audits. And then we're looking at, we're pretty confident because we got everything there. But then we got started getting some audits from our clients, and they were losing them. And this investigation I did, and it went into all the pharmacy software companies out there. If you don't, yeah, you can put an NDC. And you can actually make up an NDC. So it goes through the system. Problem is the only thing Medicare Part B the psi A once they want to know the hick pick code, and the modifiers. Your systems do not collect that data. So if you don't collect that data from the system, it's automatically going to get processed the way the billing software thinks it should be. For example, diabetics supplies, the hick pick code is a 40 to 53. However, there are two modifiers are very important. The KX modifier means the patient is on insulin, a KS modifier means that they're not. So if the modifier goes in incorrectly, it's been billed correct incorrectly, and, and the claim is, as lost. Also, there's minimum requirements are only required, like on diabetic strips, if you're doing a KS, non insulin dependent patient, you can only give 100 strips or two boxes for 90 days. There's no ifs, ands, or buts, no matter what the doctor says. That is it. If you don't do it, that way, you're going to lose the claim. If it's a KX modifier, you're going to do the same thing. Two boxes, 100 strips that for 30 day period. Okay, so if the date of service on your claim is incorrect, and it doesn't match up with the quantity dispense, it's automatically going to be rejected by Medicare. So what we found during this investigation is that it wasn't this data wasn't being collected, not your fault. The pharmacy, software's don't have it, the billing companies that are out there, don't collect it. So it's really hard for anybody to get the right data to over to Medicare. Now there are billing companies out there that you send all your documentation to them, and they will process it and put it in the right format and send it in. But you still gotta look at them and see, how familiar are they? Do they do quality work? Are there any complaints because it's like everything else. There are people that are very, very competent out there. And then you got the guy working out the back room had no clue what HIPAA code is. So So anyways, I those are the types of things that we have to have. Now, the company that I was contracted to work with, because they're they do medical billing for immunizations, is transact RX. They contracted us to do this research and help them write their software. They are collecting the hick pick code and a modifier. Also, when we help them write the software, if you are dispensing more than what is allowed, it gives you a warning light sign, and it stops you from doing a dispensing that is not correct. Remember, the doctor doesn't get to pick the type of strip or the quantity. If he says he wants to, it's a non insulin pen to tie the test three times a day don't happen. So there's also a support document you have to put it used to be called a detailed written order, where you had to get the physician to sign a written order prior to delivery the doctor had assigned before he can dispense it gone, completely got. So you have to have a document within your system. And in our system is called a D print detailed product description and lists all the items there and all you have to do is check it check the boxes or put the quantity and then go down through it. Very simple. But you also have to keep that with that standard written order for your files. Now as we move into the electronic age, you are now permitted to scan once you get all the documents together, you scan all that all the documentation right into your pharmacy software and then a patient profile for that particular script. That eliminates all that paperwork you have to keep for for Part B you have to keep it for seven years. Everything else is 10. But you can keep it in there. And you don't have to hand all this paper. Because you have too much paper as it is. So let's use electronic, but it has to be one, once it's uploaded, you want to make sure you have everything and including the EOB attached to go into your file. So, but anyways, I mean, other things that have happened, there are no more CMS, there's no more deaths. They all got eliminated on January 1 of this year. So we get calls all the time, Jeff, we can't find our CM MAN. I said, it's not there. They said, well, we need it for our diabetic supplies. I said, we eliminated three years ago. You don't need it anymore. They said, Well, we're not gonna be able to dispense it. I said, Yeah, you are looking at sample patient file, look at the policy and procedure and the portal, explains it in detail on how to do it. So be is not hard, as long as you do a very specific process. And then their documentation. That's part one. Part two, is making sure that whoever's doing your billing electronically, or manually, that they have the tools to access the information that you that they need to properly build it. Because if they're not asking for it, they're guessing. Lisa Faast: Yeah. And you mentioned the CMN. And if you're not familiar with with Medicare building, I believe that was the certification of medical need. Jeff Hedges: Certificate of medical necessity. Yeah, yeah. Lisa Faast: So that was I remember, I remember doing all that paperwork, and you had to have all these signatures. And we and it was, it was crazy. So it's very exciting to hear that actually, Medicare has eliminated some paperwork, which is usually the opposite of what they what they do. And so I want to touch on something that you had said, because this I think is a point that most pharmacy owners don't realize, because they still have that pharmacy hat on. And when you do DME and medical benefits, you have to take that off and put on the other hat is that unlike the prescription where a doctor can dictate a brand, you know, a certain a certain type, when it comes to like, say diabetic test strips or Medicare Part B drugs like a nebulizer med or something like that. A really a doctor can't say freestyle life, you know, you know, live scan strips or you know, whatever the case may be. Talk a little bit about that. And then if a patient says, But Jeff, I'm coming to you to get you know, this, you're trying to give me this test strip, I really only want freestyle, you know, what is the pharmacy to do? And does Medicare have ever paid for those? Or is it just the flat amount and you got to figure it out? So talk a little bit about that. Because I think there is a lot of mythologies around that when it comes to specific brands. Jeff Hedges: Okay, good. So the doctor writes, he wants one touch, which goes to a previous car car, podcast we just did. But he writes it, he wants a four times a day non insulin dependent, don't care about anything, you will dispense. One Touch straps. They're expensive. They're far more than what the Medicare lobortis. So, but they can't dictate that it no matter what they want to do, they can't dictate then they can't change CMS requirements. And those are all listed on the local coverage, determination or LCD. What happens on that? So when I explained it, the doctor I explained it to pharmacies, I said, so the doctor ordered is a pair of crutches or a wheelchair and he's beside specifically named a brand. Do you Spence it, is what he's saying. Well, of course not. We went, Okay, diabetic strips is DME. So no matter what the doc says, You don't dispense it. Okay. You dispense what Medicare does not want you This is unlike the PBMs. Medicare does not want you to lose money dispensing their products. There are products that are below the the Allowable Fees that Medicare's pay us those products patients want to complain about. That's fine. This is Smith. I know your doctor wants you to use Ultra one touch, but Medicare's only permitting me to use a true track scribe. Now if you want the one touch we can sell to you. But there's a couple things you have to know. First, we need to do it advanced beneficiary notice or ABN. We're going to fill it out we'll put in what the the full fee is for the for the reimbursement, which is your usual customary for one touch. They have to pay the 20% plus the difference between the allowable and their and your usual customary Not what you send into Medicare. But what your usual customary is, which is your cash price? Well, they see why I can't afford $120 for a box. Exactly, we can't dispense it. And if we dispense that we lose everything. So you'd have to explain that to the patient. Now, the PBMs are gonna get upset with you if you do that on their drugs. Now, I'm part B. But we're talking DME here. So you educate the patients is how to dispense of what they're authorized. Don't keep it secret, say you're only authorized to one test per day, because you're not insolence pennant, congratulations. So and you don't need to have your fingers all messed up by by the needle breaks down, we move into this continuous glucose monitor process, that has just changed. And actually, it's changed three times, I think, in the last three, four months. Lisa Faast: Yeah, I've stopped trying to keep up. Jeff Hedges: Well, my staff outside the recording studio right now they're actually working on continuous glucose monitors. And I haven't been given the latest change. But the biggest thing is, as if you're doing continuous glucose monitors, if you're using us, we'll be updating that's what they're gonna it's going to be updated later today. But you got to read the local coverage determination LCD, now used to be all four, d max had their own. Now these are managed by CMS, it covers all four d max, so you got a you only have one process to do. But these things change. LCDs, like I mentioned earlier, are constantly being updated. And sometimes they don't change the date. So they make a change in it and keep the original date. So you don't even realize that has been changed and you're out of compliance. So CMS is famous for doing that. Lisa Faast: Yeah. Where can pharmacies find their LCDs? Like is there you know, the best website, obviously, if they're your customers, you know, you're keeping them updated. But if somebody's listening to this, and they're like, holy moly, like I didn't even know these things out there existed. Where can a pharmacy go find you know, what is at least the the latest LCD Jeff Hedges: LCDs are easy to find, you should know who your D Mac is what region you're in. Okay, now, there's only two contractors now Noridian, D, Mac, A and D, and C D, G. CGS. SHGs is Benny takes care of B, and C, when you go on to their sites, and you go into DME, Part B, they'll see on the side, LCD, click on that, and it'll give you all think we're at 57 LCDs. And they're not a single page document. Some of these things are 25 pages long. And that's after they pulled the documentation requirement out and had their own LCD for just the documentation. You gotta read them. If you're dispensing someone has to read them and make sure you're in compliance because a modifier may apply to one of the items on the LCD, but not to another. And there's just got to know that information, whoever is DMA is managing your DMA. They have to know this. Now, one of the other questions I always get, some of you are gonna like me, and some of you're gonna hate me right now. They said, Jeff, I can't find anybody to do this. For me that knows what they're talking about. I said, two choices, you can send them to our office and we'll try to train them or find out who the best biller is in town for whether the DME facility or pharmacy and go off from $1 More an hour and bring them over to your site Lisa Faast: might take a little more than $1 more than our these days. But yes, that is a definitely a strategy that I know some people have employed like apps, absolutely, you're spot on. So if you're listening to this, and you are in the DND space want to get in the DME space, once we expand, it can be a really great space. Um, you just you got to, you know, hit all the regulatory things, you know, head on and, and really take a proactive approach to that. And you're interested in learning more of how you know, Jeff and his team, which has like one of the best teams in pharmacy is gotta say, I love everybody over there. Jeff, how can I get a hold of you if this is something that they want to pursue, pursue and go further with? Jeff Hedges: Okay, sounds good. First off, the fallacy that you can't make money in DME is gone. Yeah. Okay, so you can make money as long as you do it right, especially diabetic shoes, you're still making $300 on a pair of shoes. Okay, so contact us, you can go to our website .rjhedges.com We have all kinds of information up there we have videos, some of the programs you can order online, depending on what you need, or what you have, or you can send us an email at sales at rj hedges.com or call us at 724-357-8380 You'll probably be routed to Jenny, and she's just fun to talk to. So but that is to help you I mean, we can help you. And yes, some people will say we're a little expensive, but you get exactly what you pay for it. Lisa Faast: So those those that $99 We have to be compliant and everything programs um, you know, they might work if you spend you know, 20 hours a you know, seems like 20 hours a day working on them, but you definitely get what you're paid for and I actually love your guys's offerings now, you know, with the bundles like hey, if you need a bunch of these things, here's this but hey, if you just need a few things, Allah cart out there because as as independent pharmacies are following some advices of you know, getting more niched getting more focus, you know, you might only need to, you know, you don't want only to be worried about a few things, you don't need to worry about everything. So, thank you so much for your time in this, Jeff, you, you've helped us with this entire compliance series. And we still have more to come if you're listening to this. If you didn't catch some of our earlier episodes, go back and listen to those because there are a ton of compliant factors coming up at the end of 2023. And in particular November, we want to make sure that you're aware of all those. So thank you so much, Jeff, and I look forward to chatting with you again. Jeff Hedges: Okay, thank you and have a great day, everyone.