Author Topic: Billing Meds for ASCs  (Read 702 times)

Scott

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Billing Meds for ASCs
« on: February 01, 2017, 12:10:10 PM »
Hi all.  I appreciate your help.  I have an ambulatory surgical center who is interested in billing medications/injections they use during procedures through a patient's pharmacy benefit plan instead of through their medical benefits.  I've confirmed that I can credential an ASC with PBMs which would allow them to adjudicate their medications using the patient's Rx benefits, but a question came up recently regarding whether or not an ASC was required by law/contract to bill medications through medical. Does anyone have experience billing for ASCs and whether or not there would be anything precluding us from billing their medications through the pharmacy side?
Thanks. Scott

Michele

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Re: Billing Meds for ASCs
« Reply #1 on: February 02, 2017, 02:30:05 PM »
I do not have any direct experience in this.  I tried to do a bit of research but no luck.  Do you belong to any organizations that may be able to provide some insight?  Or at least where you can find documentation?  You may also try to reach out to one of the major insurance carriers to ask for their guidelines.

Good luck
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RichardP

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Re: Billing Meds for ASCs
« Reply #2 on: February 03, 2017, 03:16:37 PM »
If you google "pharmacy benefit plan", you will see that these plans cover prescription medication.  You have an ambulatory surgical center who is interested in billing medications/injections they use during procedures.

Apples and Oranges.

kristin

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Re: Billing Meds for ASCs
« Reply #3 on: February 03, 2017, 06:53:58 PM »
That was my thought on it too, Richard. If it isn't a prescription, you can't bill it through PMB.

Not sure how medications that an ASC would be giving to a patient during surgery or through an injection would qualify as a PMB. But maybe I am not understanding the question clearly enough.

Scott

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Re: Billing Meds for ASCs
« Reply #4 on: February 06, 2017, 03:21:26 PM »
Thanks for responding.  Not sure if this would help, but I thought I'd provide some background.  One of the services we offer is to set up physician offices to be their own dispensers.  So, in essence, they prescribe medications which they also fill.  Dispensing physicians are similar to pharmacies with the difference being they cannot dispense medications or administer injections to anyone who isn't their patient.  When we credential a physician with a PBM, the PBM views them exactly the same as if they were a pharmacy and will allow medications to be adjudicated exactly the same way as if they were a CVS.

Injections, like regular meds, have an NDC that can be transmitted to and paid by a PBM.  We adjudicate injections used during procedures in Dr's office all the time.  However, all of our clients to this point have been physicians operating out of their offices.  I'm trying to determine if an ASC is similar to a physician's office (vs a hospital which we don't do) and therefore doesn't have any special rule (legally or contractually) which wouldn't allow me to bill the NDC related to the injection under the patient's pharmacy benefit plan instead of medical.

Michele

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Re: Billing Meds for ASCs
« Reply #5 on: February 07, 2017, 10:43:22 AM »
Based on that information it sounds like you need to check with the insurance carriers to see if you can be set up as an  ASC and a pharmacy.  If so, then you would be able to bill the medications out as the pharmacy.
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