Can anyone explain how no-fault insurance work? is it no-fault, or NOT-FRAUD rx claim?

[apple212]

I dont have any experience with how no fault insurance/prescriptions claims works, WHATSOEVER!! I have experience with worker comp and it is such a hassle because you have to deal with patient and the case #, and adjusters that approve or deny your claim. But currently I am working at an independent pharmacy and I get a packet of paperwork with the accident report of the no-fault, and the various insurance information on the car accident, and a facsimile copy of the medical report from the physician, along with a facsimile copy of a prescription form that just have boxes of meds and doses in which is circled or checked off (ie. ibuprofen, naproxen, diclofenac gels ) . However I keep telling my supervising pharmacist that I refuse to fill any prescriptions unless it is an e-script (based on NY state laws)... however my supervising pharmacist keeps insisting that with no-fault claims, the documents are suffice to fill a prescription.

And additionally who do you bill for the prescriptions? Do you bill the patient's insurance or do you waiver the cost of the prescription, because the no-fault will pick up the charges (seems very suspect to waiver fees)?
I truly have no experience and/or idea on no fault claims, so if anyone could help inform me, it's much appreciated!!

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[BidingMyTime]

With workman's comp, you would bill whoever is covering the workman's comp claim. If you bill the insurance, the pt would have pay the normal co-pay, and then it would be the patient's responsibility to ask for a refund from the workman's comp company.

No idea on the NY law, other to say if there was an exception, it would be spelled out in the law, so your best best bet is to look through a copy of the law and see what it says.

 

[WorthlessOxygen]

For both worker's comp and no fault, I was under the impression that intentionally billing the patient's prescription insurance runs close to fraudulent billing. I know my chain uses Mitchell/AutoRx as the third party for any no fault claims and we just have to put in the claim number and auto insurance provdier, they handle all approvals.

As far as state law, the prescriptions that you are describing are not valid in New York. You could make them compliant by calling the provider and verbally confirming everything, appropriately documenting, then entering them as new verbal orders.

 

[Sine Cura]

However I keep telling my supervising pharmacist that I refuse to fill any prescriptions unless it is an e-script (based on NY state laws)... however my supervising pharmacist keeps insisting that with no-fault claims, the documents are suffice to fill a prescription.

WTF does "no fault" have to do with prescription requirements?

No pharmacy claims processing info (i.e., BIN/PCN), the pt can pay out of pocket and seek reimbursement later.

 

[owlegrad]

Workers Comp is a huge PITA. You should not be billing the patient’s insurance though. At CVS there was a process to run those claims through a third party like Oxygen outlined and I only barely recall it. I do recall a lot of denied claims and upset patients.

I am not in NY so I don’t know about that part.

 

[RxPreceptor]

No fault, person has to fill out form and fax completed form before claims will be paid out. I keep a bunch of spare copies handy, check with another RPh in store if yous guys have forms...PIA might have to call to get fax form sent to you if yous guys don't have any available

Usually need auto insurance policy #; haven't done one of these in a while, I usually just look at said form and go from there.
Yes, no fault is just for billing/3rd party (still need an Rx!)

Note: there are waivers for e-scribing, notably ER settings (paper hard copies still the NORM). You sound quite green if you are refusing to fill anything other than e-scripts

 

[WorthlessOxygen]

Note: there are waivers for e-scribing, notably ER settings (paper hard copies still the NORM). You sound quite green if you are refusing to fill anything other than e-scripts

There are blanket waivers based on practice setting and annual number of scripts written, plus additional ones that prescribers can apply for. OP can see NYS DOH for more information here Exceptions to Electronic Prescribing

That being said, the faxes described are not in compliance anyway as faxed prescriptions still have to be on official new york blanks. They also cannot be pre-printed with the actual orders circled/checked off.

 

[Sparda29]

Pain in the ass with these.

Do not bill the patient's regular insurance.

 

[apple212]

For workers comp and no fault, we dont bill the patient's direct insurance. we process thru the worker comp (BIN 003858 /PCN ), and usually thereafter deal with lawyers and adjusters that deny or approve the claim

With no-fault, insurance company for the car that you were in at the time of the accident provides you with no-fault insurance that covers your medical bills and lost wages. My question is, if a patient gets a prescription for like Diclofenac gel 3%, which has an out-of-pocket cost that is about $500 to > $1000 (based on the quantity). The pharmacist says we are supposed to waiver the cost of the medication, and hence the patient pays $0 as their out of pocket cost (so who covers for the cost of the medication, and how are you certain no-fault will be able to get coverage/ approval for the prescriptions?)

 

[WorthlessOxygen]

For workers comp and no fault, we dont bill the patient's direct insurance. we process thru the worker comp (BIN 003858 /PCN ), and usually thereafter deal with lawyers and adjusters that deny or approve the claim

With no-fault, insurance company for the car that you were in at the time of the accident provides you with no-fault insurance that covers your medical bills and lost wages. My question is, if a patient gets a prescription for like Diclofenac gel 3%, which has an out-of-pocket cost that is about $500 to > $1000 (based on the quantity). The pharmacist says we are supposed to waiver the cost of the medication, and hence the patient pays $0 as their out of pocket cost (so who covers for the cost of the medication, and how are you certain no-fault will be able to get coverage/ approval for the prescriptions?)

Still unclear with how you are billing things for no fault. How do you actually submit the claim to the auto insurance? Unless you have a paid claim, I don't see any way to guarantee that you will recoup the lost cost of the medication.

Maybe you're being told to waive the cost because the medication was approved and the auto insurance will cut a check directly to the pharmacy? That sounds like a question for the pharmacist who told you to waive the cost though.

If an approval decision is still pending I would have the patient pay out of pocket and try to independently seek reimbursement from the insurance because I have no way of knowing that the claim will ultimately be approved.

 

[Sparda29]

Still unclear with how you are billing things for no fault. How do you actually submit the claim to the auto insurance? Unless you have a paid claim, I don't see any way to guarantee that you will recoup the lost cost of the medication.

Maybe you're being told to waive the cost because the medication was approved and the auto insurance will cut a check directly to the pharmacy? That sounds like a question for the pharmacist who told you to waive the cost though.

If an approval decision is still pending I would have the patient pay out of pocket and try to independently seek reimbursement from the insurance because I have no way of knowing that the claim will ultimately be approved.

It's confusing, I think I remember when we worked with no-fault, we just gave the drugs out for no-cost and then sent a bill to the patient's lawyer's office to submit the overall package to the insurance for reimbursement.

 

[WorthlessOxygen]

It's confusing, I think I remember when we worked with no-fault, we just gave the drugs out for no-cost and then sent a bill to the patient's lawyer's office to submit the overall package to the insurance for reimbursement.

Sounds like what OP's pharmacy does too. I'd have a hard time trusting that the pharmacy would actually end up getting paid in the case of denied claims. Do you know who ate the cost when drugs were denied?

 

[Sparda29]

Sounds like what OP's pharmacy does too. I'd have a hard time trusting that the pharmacy would actually end up getting paid in the case of denied claims. Do you know who ate the cost when drugs were denied?

Pretty sure that was the cost of doing business. Owner ate it. They made plenty of profit to make up for losses like that.

 

[wazoodog]

There is a reason why it's hard to find a specialist in NYC that will accept no-fault...especially in neurosurgery an neurology.

 

[apple212]

Still unclear with how you are billing things for no fault. How do you actually submit the claim to the auto insurance? Unless you have a paid claim, I don't see any way to guarantee that you will recoup the lost cost of the medication.

Maybe you're being told to waive the cost because the medication was approved and the auto insurance will cut a check directly to the pharmacy? That sounds like a question for the pharmacist who told you to waive the cost though.

If an approval decision is still pending I would have the patient pay out of pocket and try to independently seek reimbursement from the insurance because I have no way of knowing that the claim will ultimately be approved.

Like I said i have zero experience with no-fault... Therefore, if the pharmacy were to waiver the cost of the medication (wouldnt that mean there is no guarantee that the pharmacy would be fully/properly reimbursed? ) ... however the supervising pharmacist said that when we waiver the out-of-pocket cost of the prescription, that with no-fault insurance, they would still somehow get reimbursed for the prescription.... hence I find no-fault very confusing as to how they would get reimbursed properly...