Overcharging MTM Services Beyond State-Regulated Amounts
Definition
Pharmacies charging SeniorCare members more than remittance-specified amounts for MTM services violate state statutes, requiring mandatory refunds and risking penalties. Providers must track spenddown/deductible status precisely, but failures lead to overcharges and refund obligations. Systemic compliance demands real-time eligibility verification to avoid legal repercussions.
Key Findings
- Financial Impact: Refunds plus potential fines under Wis. Stat. § 49.688(5)(a)
- Frequency: Per overcharged claim - recurring until eligibility systems improved
- Root Cause: Inadequate real-time access to member spenddown/deductible data from payers
Why This Matters
This pain point represents a significant opportunity for B2B solutions targeting Retail Pharmacies.
Affected Stakeholders
frontline pharmacists, billing teams, pharmacy owners
Deep Analysis (Premium)
Financial Impact
$1,000-$3,000/month in claim rejections, refund processing, and re-billing cycles • $1,500-$4,000/month in member disputes, refund coordination, and coordinator time re-reconciliation • $1,500-$5,000/month in refund processing overhead and SeniorCare clawbacks; reputational risk with state regulators
Current Workarounds
Billing Specialist manually cross-references remittance advice before submitting; maintains ad-hoc Excel lookup tables for SeniorCare deductible thresholds; corrects claims after denial • Clinical Pharmacist delivers service and estimates billing based on assumptions; documentation relies on staff follow-up to verify member cost responsibility; retroactive charge correction if overcharge detected • Compliance Officer manually reconciles claims against remittance limits; generates refund lists in Excel; coordinates refund processing via email/phone; documents corrective actions for audits
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Methodology & Sources
Data collected via OSINT from regulatory filings, industry audits, and verified case studies.
Related Business Risks
Medicare Fraud Risk from Unbilled Parallel MTM Services
Incorrect MTM Billing Codes Leading to Zero Reimbursement
Denied MTM Claims Due to New vs Established Patient Coding Errors
Failure to Receive 340B Ceiling Prices from Manufacturers
Diversion and Duplicate Discount Violations in Contract Pharmacies
HRSA Audit Failures and Required Repayments for Diversion/Duplicate Discounts
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