What is split billing?
Split billing, in pharmacy, is the process of submitting a single claim to
multiple payers for combined reimbursement. When a patient has dual coverage, a
coupon card, or is entering/leaving a facility – the billing procedure changes
(and then is considered split billing). Split billing can introduce many subtle
but complex scenarios that can result in reimbursement issues and delays. The
extra time to process and complicated coding (such as other coverage codes)
impacts the pharmacy workflow and reimbursement.
As a Pharmacy Technician, the main goal is to provide patients with the
medication they need in a timely manner. Processing prescriptions quickly to
get medication out the door is ideal for patient satisfaction as well as
pharmacy workflow efficiencies. Beyond some typical things that could slow down
the process of billing prescriptions (such as rejections, formulary
restrictions, inventory challenges, eligibility issues), the intricacy of split
billing and the associated coverage codes make it even more complex. Split
billing takes additional time to process and includes complicated coding that
can unexpectedly impact reimbursement. It is important to review claims before,
during, and after adjudication especially in a split bill scenario for accuracy
to help reduce underpayments/losses, retroactive adjustments on your claim, and
copay/deductible changes for the patient. When you bill every claim correctly
to begin with, or use pre edit technology to help ensure claim accuracy, it saves time for everyone,
and your billing expertise and consistent results will undoubtedly impress your
Pharmacy Manager and help your pharmacy’s profitability.
There are different types of split billing including 340B,
secondary coupon cards, Coordination of Benefits (COB), and Med-A (facility/hospital) split billing.
- When a pharmacy claim must be divided between 340B eligible
areas and the inpatient or hospital charges, a claim can be 340B split billed.
- Coupon cards are common in retail pharmacies but are not
eligible with Medicare Part D reimbursement. A coupon card, or a pharmacy
discount card, is usually a free card that allows the patient to save a little
extra on certain medications. Some are marketed by drug manufactures and some
are offered by companies or other commercially available organizations. It is
important for a pharmacy to reconcile coupon card claims to
ensure they do not have negative impact.
- Coordination of Benefits refers to the fact that you are billing
the same prescription and expecting a cost share arrangement when there is more
than one active coverage. The primary insurer pays a portion and the secondary
pays any remaining amount, in most cases to help eliminate or lower the cost to
the patient. Although COB is generally used when one of the payers is Medicare
D, it is also referenced when there is more than one active Commercial
Insurance for a patient, or even Medicaid in addition to Med D or Commercial.
- With Med-A split bills, the payment arrangement is between
coverage for a hospital/facility and the normal prescription insurance. When
the patient is discharged/admitted or moves to/from a facility – the
prescription quantity remaining must be billed to the alternative coverage.
NCPDP defines Submission Clarification Code 19 as “Split Billing -
Indicates the quantity dispensed is the remainder billed to a subsequent payer
when Medicare Part A expires. Used only in long-term care settings.” In
many cases, the Medicare A invoices are not adjudicated, so this code is
utilized to tell the prescription coverage payer when the quantity being billed
is the remaining quantity.
The coding that is required for any type of split billed claim
can be complicated and difficult to understand. It can even be different for
each payer. Formulary conflicts between two plans
can also impact this process. To get the medication to the patient who is
waiting, you want to get the claim paid as fast as possible. It can be tempting
to enter override codes that may be accepted but could result in inaccuracy;
however this can lead to underpayment and potential losses.
To learn more about the when to
use pre-edit and post edits, read
“Prescription Claim Billing – Benefits of a Pre and Post
Edit Solution.”
When a patient has secondary insurance coverage and a claim is being split billed, the pharmacy technician and/or the billing team needs to understand other coverage code definitions and ensure they are applied correctly. Ensuring that the other coverage code is accurate ensures the patient's pay amount is correct, to alleviate any retrospective updates for the patient. To help take the guess work out of it, here are the available other coverage codes, which should be populated in field 308-C8, as applicable:
As you can see, communicating claim information to the downstream payer(s) when split billing can affect the patients' copay amount. Other Coverage Codes are not the only codes critical for accurate billing. Here are some additional fields that affect your patients and your claims:
Each Payer publishes a payer sheet that is based on the NCPDP standards for prescription coding. When you are trying to get your claims paid so you can fill prescriptions quickly, there is little time to reference payer sheets. Therefore, it is important to know the coding required for split billing up front and how it impacts your claims.
Changes in a patient's insurance coverage can cause additional challenges in the billing workflow. When resubmitting a claim from one insurance and/or facility to another (split billing), it is crucial that you recalculate or update the pricing on that claim. For example, from Med A facility to Med D, or even Med D to commercial, if this step is not completed (or is completed incorrectly), an inaccurate AWP, gross amount due, or total amount billed may be submitted to the secondary payer, causing inaccurate reimbursement. It is easy to forget this step but it is critical for proper reimbursement. If this is part of your workflow, or better yet built into your pre edit solution, your claim is better equipped for smooth processing.
Each pharmacy dispensing software may recalculate or update split bill pricing differently. So, this step in the billing process may be initiated at different times and in different ways. Sometimes it is initiated by pressing the space bar or "Tab" within the prescription editing screen. Some dispense systems have a button to "re-calculate" or "update pricing". Others require you to re-enter the prescription quantity and press "Enter". It is important to know how your pharmacy software works and what steps need to be taken between each stage or step in your prescription billing process. If you are unsure, or just need some expert guidance, ask your Net-Rx analyst. If your dispensing software isn't updating the pricing when you shift from facility pay to PBM, or from one payer to another, reach out to your software vendor's support team to ensure you are following the best practices for that system. Also confirm that your software system is updated regularly to ensure it is operating properly. Software updates are important not only for security patching but also for other operational and regulatory updates.
Split billing does have its complications. As a pharmacy technician, a biller, or even a pharmacy manager, accurately completing each billing transaction associated with a prescription, especially during split billing, is essential for a smooth and efficient billing function and a profitable pharmacy. There are manual ways to mitigate issues, or better yet, a technology solution such as pre & post edit check can save pharmacy staff time, while optimizing reimbursements and ensuring the patient has an accurate copayment.
Click here or call us at 866-336-3879 to learn more about how Net-Rx can help you with billing and reimbursement.
Read more articles that cover topics such as DAW Codes and Short-Cycle Rules.
Author:
 | Jennifer Gordon 
Product Lead
Joined Net-Rx in December 2013 |
Jennifer Gordon is intimately involved with bringing new technology products and services to the marketplace to provide solutions for pharmacies' business needs. Her philosophy is to learn as much as she can to improve pharmacies' business journey and better the industry's health.
Jennifer's career in pharmacy began 12 years ago as a CPhT technician. Her love of pharmacy operations drove her to work hard to ensure the pharmacy ran smoothly and patient care was held to the highest quality standard. To further her education, Jennifer earned her Associates of Science degree in 2012 and thrived on the knowledge and experience she gathered throughout the healthcare industry. She then acquired her billing and reimbursement certification from the Pharmacy Technician Certification Board.
Jennifer began her career at MHA as an account analyst responsible for managing accounts across the nation by providing guidance, education, and training to ensure pharmacies were operating efficiently to receive maximum reimbursement. Her abilities and successes were recognized and rewarded in her promotions to Team Lead and then to Product Lead, where she currently manages all Net-Rx portfolio products.