Insurance Company Defining AWP
We have an insurance company who redefined AWP as CMS plus a percent rather than using Redbook or other source for AWP pricing and is now recouping for the difference of AWP and their redefined amount. Has anyone else had this occur? If so, how was it addressed? Appeals have been denied. Any suggestions?
Submitted by: Todd Thompson, RPh
Response Summary
There were 5 Listserv responses to Todd’s question. In summary, all responses suggested that a review of your contract with the insurance company was in order. If the contract language is vague or the insurance company is taking liberty to interpret the wording to take advantage of more favorable pricing rates, then filing a complaint with your state insurance commissioner would be in order. Other avenues would be to file a complaint with entity accrediting that particular payer, i.e. URAC or NCQA. They all recommended that you should appeal or stall the recoupment of monies until you have met face to face with the carrier.
Rock-Pond Analysis
Pricing and reimbursement for our products and services in this industry should not be this difficult. We have to interpret the coverage guideline language from Part B Medicare Enteral and Parenteral manual on acceptance of patients without complete knowledge of whether we will be paid or not. Now the insurance industry is taking liberty at determining what the standard practice for medication reimbursement should be.
Before any patients are accepted into your service, a complete understanding of the clinical and financial risks must be assessed. Your company must establish guidelines for patient acceptance prior to services being offered. If there are any exceptions to your organizations patient acceptance guidelines, then there should be an interdisciplinary team meeting to discuss and assess the risk variables.