Denied MTM Claims Due to New vs Established Patient Coding Errors

$1,040-$2,960/month per pharmacy location (20 denied claims × $52-$148); increases with claim volume • $1,560-$4,440/month per pharmacy (30 Medicaid MTM claims × $52-$148); Medicaid volume typically higher • $10,000-$30,000/month per multi-location pharmacy (assumed 200 MTM services/month across locations × 5-10% denial rate × $100 avg); hidden compliance fines ($5,000-$50,000) if patterns show systematic abuse

Asks patient 'Have we done this before?'; documents verbatim patient answer; submits claim with uncertainty; faces rejection post-billing • Asks patient verbally; searches patient file manually; defaults to 'established' code when unsure; handles claim denial post-billing with rework • Calls clinic manager before each MTM; checks printed Medicaid plan summary; documents ruling on session notes; codes conservatively