Expert Tip From Cloudmed

Small technical errors can cause eligible claims to be misclassified as ineligible. On average,our clients typically find an additional 2% or more in misclassified claims from prescriptions written by employed providers.  There could be several reasons why claims can be falsely identified as ineligible: 

1. Incorrect provider list or patient characteristics 
2. Missing wholesale / manufacturer pricing 
3. Incorrect Medicaid status 
4. Flawed TPA settings that disqualify eligible claims  
5. Missing data from EMR  

Additionally, assess your referral opportunities if your covered entity refers patients to ineligible 340B locations for care. Understanding what ineligible claims you really have access to is the first step of building a 340B referral program. TPA dependent covered entities may: A) not have access to any ineligible claims, B) only have access to ineligible claims if a patient has had an encounter at the CE recently, or C) have access to all ineligible claims if the patient has ever had an encounter with the CE.

Once you determine there is referral opportunity, make sure you choose the right partner for your needs. Referral claim audits can require manual verification for each claim, and additional internal support may not be available.