Reimbursement Solutions

Tips to Streamline the Reimbursement Process - Insurance providers only approve claims that are submitted in the correct format with the correct documentation. Physicians dealing with private insurance and workers compensation claims can assist the process by providing complete documentation on the medical record. The practice of accurate patient progress charting is essential to the reimbursement of a private insurance and Workers Compensation Claim.

Workers Comp Physicians
Items to list on the Physician's Progress Report (PR2)

  • List products by brand name, rather ingredients when making notes.
  • Establish medical necessity. Chart the method employed to determine level of pain, discomfort, depression, or other symptoms.
  • Indicate your intention to use a specific prescription for treatment.

Items to AVOID listing on the PR2

  • Dietary supplements, vitamins, and other OTC medications are not included on the fee schedule and are rarely reimbursed.
  • Avoid listing the ingredients of the products prescribed in lieu of the product name.

Private Insurance Physicians
Understanding the Formulary is Essential for Appropriate Reimbursement

The formulary system, when properly designed and implemented, can promote rational, clinically appropriate, safe, and cost-effective drug therapy. In order to achieve optimal third party reimbursements, it is essential for dispensing physicians to familiarize themselves with acceptable formulary medications as well as the process of formulary development.

Dispensing physicians will develop their own formulary over time as it pertains to their practice needs. Complete Claims Processing Inc. will provide physicians the reimbursement and dispensing data needed to make informed and accurate decisions when the formulary needs to be amended. CCPI will assist physician clients to maximize the potential of their practice formulary for patient care and cost effectiveness.



Drug Formulary System - an ongoing process whereby a health care organization, through its physicians, pharmacists, and other health care professionals, establishes policies on the use of drug products and therapies, and identifies drug products and therapies that are the most medically appropriate and cost-effective to best serve the health interests of a given patient population.

Drug Formulary - a continually updated list of medications and related information, representing the clinical judgment of physicians, pharmacists and other experts in the diagnosis and/or treatment of disease and promotion of health.

Therapeutic Alternates - drug products with different chemical structures but which are of the same pharmacological and/or therapeutic class, and usually can be expected to have similar therapeutic effects and adverse reaction profiles when administered to patients in therapeutically equivalent doses.

Therapeutic Interchange - authorized exchange of therapeutic alternates in accordance with previously established and approved written guidelines or protocols within a formulary system.

Therapeutic Substitution - the act of dispensing a therapeutic alternate for the drug product prescribed without prior authorization of the prescriber. This is an illegal act because only the prescriber may authorize an exchange of therapeutic alternates.

The formulary system

  • Provides drug product selection and formulary maintenance.
  • Provides drug use evaluation (also called drug utilization review) to enhance quality of care for patients by assuring appropriate drug therapy.
  • Provides for the periodic evaluation and analysis of treatment protocols and procedures to ensure that they are up-to-date and are consistent with optimum therapeutics.
  • Provides for the monitoring, reporting, and analysis of adverse results of drug therapy (e.g., adverse drug reactions, medication errors) to continuously improve the quality of care.

The Pharmacy and Therapeutics Committee

  • Objectively appraises, evaluates, and selects drugs for the formulary.
  • Meets as frequently as is necessary to review and update the appropriateness of the formulary system in light of new drugs and new indications, uses, or warnings affecting existing drugs.
  • Establishes policies and procedures to educate and inform health care providers about drug products, usage, and committee decisions.
  • Oversees quality improvement programs that employ drug use evaluation. Implements generic substitution and therapeutic interchange programs that authorize exchange of therapeutic alternatives based upon written guidelines or protocols within a formulary system. (Note: Therapeutic substitution, the dispensing of therapeutic alternates without the prescriber’s approval, is illegal and should not be allowed-See Glossary.)
  • Develops protocols and procedures for the use of and access to non-formulary drug products.
  • Health care organization policies should ensure appropriate oversight of the P&T Committee and its decisions by the medical staff or equivalent body.


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