Pharmacy Blog
Examinations in Drugstores
With effect from January 15, 2022, individuals with health plans can purchase an FDA-approved COVID-19 diagnostic test over-the-counter for use at home for free, either through insurance reimbursement or without charge at a pharmacy or retail location. In order to avoid the hassle of having to submit claims for reimbursement, CMS is strongly encouraging health plans and insurers to establish a network of easily accessible locations across the nation, such as pharmacies or retailers, where individuals with private health coverage can order online or walk in and pick up at-home over-the-counter COVID-19 tests for free. Insurance companies will pay up to $12 per person in reimbursement. test (or, if it is less than $12, the test’s cost). By reading this blog post regarding pharmacy testing and reimbursement procedures, you can improve revenue cycle management and increase your earnings.
Insurance Payments for Testing at Drugstores
It is permissible to cap the per test reimbursement amount for retailers outside of a network that the plan or insurer establishes if it wants to provide convenient options, like pharmacies or online retailers, where members of the plan can get their test costs covered up front (at the point of sale). In particular, if a plan or insurer creates this kind of direct coverage option, they can set a reimbursement cap of $12 per test (or the test’s real cost, if less) for tests bought outside of its network. A lot of the commercially accessible at-home tests cost $12 or less per. If the insurer or plan does not specify if they set up a procedure that allows people to get tested without paying anything up front, then the insurer and plan have to pay for the test in full, even if it ends up costing more than $12. For instance, in the event that a person purchases a two-pack for $34, and the plan or insurer does not have a mechanism in place to pay for expenses up front, the $34 would have to be reimbursed rather than $24.
Invoicing for No-Impact
Certain community health centers also provide free at-home tests to those without insurance. The first delivery of 500 million free over-the-counter at-home tests to all eligible Americans will begin in January 2022, thanks to a purchase made by the Biden-Harris Administration. Americans would be able to obtain free at-home tests for home delivery via a website. Soon, further details about this federal program should be available. Furthermore, community health centers and Medicare-certified health clinics would receive up to 50 million free at-home tests from the U.S. Department of Health and Human Services (HHS) to distribute to patients and community members at no cost. By December 21, 2021, every health facility funded by the Health Resources and Services Administration (HRSA), and after completing the onboarding procedure, rural health clinics with Medicare certification are qualified to take part in the program.
Purchasing Multiple Tests at Once
Regardless of whether the tests are purchased all at once or at different periods during the month, each person enrolled in the standard health plan will be reimbursed for eight tests per month. A health plan may cap the reimbursement for tests purchased outside of their network at $12 per test (or the actual cost of the test, if less than $12) if the plan has established a network of convenient locations, such as pharmacies and retailers, where people can get their test costs covered upfront (at the point of sale). If additional When more than one test is ordered or purchased at once—for example, a package containing two tests—the insurance will pay up to $12 for each test that was ordered at that time.
Medicare Protection
Medicare pays for laboratory-performed COVID-19 diagnostic tests, such as PCR and antigen tests, for individuals covered by original fee-for-service Medicare. When a doctor, non-physician practitioner, pharmacist, or other authorized health care provider orders the test, there is no beneficiary cost-sharing. Medicare beneficiaries are eligible for one cost-free lab test per patient annually without a prescription. At present time, at-home tests covered by this program are not covered by original Medicare. Customers covered by Medicare Advantage should verify with their plan as it may provide coverage and payment for at-home over-the-counter COVID-19 tests.
Coverage of Medicaid and CHIP Programs
The FDA-approved at-home COVID-19 tests must be covered by State Medicaid and CHIP programs, according the American Rescue Plan. For information about the specifics of coverage for at-home COVID-19 testing, those with Medicaid or CHIP coverage should get in touch with their state’s Medicaid or CHIP agency. Please note that state-specific coverage rules may differ.
Leading medical billing provider ProviderBillingandCoding(PBC) offers full revenue cycle management services. Please get in touch with us if you have any questions concerning insurance reimbursement for the COVID-19 diagnostic test. With their familiarity with the most recent pharmacy billing developments, our billing and coding specialists can help you obtain precise insurance payments. For additional information about comprehensive pharmacy coding and billing services.