9/30/2018 1 9/30/2018 Audits: How to Protect Your Bottom Line - - PDF document

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9/30/2018 1 9/30/2018 Audits: How to Protect Your Bottom Line - - PDF document

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9/30/2018 1 9/30/2018 Audits: How to Protect Your Bottom Line NCPA 2018 Annual Convention Amanda Gaddy, RPh Director of Clinical Services Georgia Pharmacy Association Disclosure Amanda Gaddy is a pharmacy consultant and is receiving an

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Amanda Gaddy, RPh Director of Clinical Services Georgia Pharmacy Association NCPA 2018 Annual Convention

Audits: How to Protect Your Bottom Line

Disclosure

Amanda Gaddy is a pharmacy consultant and is receiving an honorarium for this

  • program. The conflict of interest was resolved by peer review of the content.
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Learning Objectives

  • 1. Review new developments in pharmacy audit recoveries.
  • 2. Discuss red flags and actions to ensure procedures are

followed to eliminate risk.

  • 3. Outline your audit rights and responsibilities.

Audits for Discussion Today

  • Desk Audit

Request for copies of prescription records

  • On-site Audit

Personal visit from Auditor

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WHY AUDIT?

1) Prevent Fraud, Waste and Abuse 2) Ensure proper payment by PBM on behalf of the health plan and patient Pharmacies are still billing incorrectly

LEARN THE GAME! KNOWLEDGE IS POWER!

Red Flags and Common Discrepancies

  • Day Supply must be EXACT and match quantity prescribed and directions for

use

  • Insulin
  • Allow the claim to reject and call for a prior auth if necessary
  • NEVER force a days supply to reduce copay
  • Factor in storage life of insulin
  • Eye Drops
  • Varies between PBMs- 20 drops per ml is a good standard
  • Ointments/Topicals
  • Document frequency and area of application
  • Fingertip units
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Red Flags and Common Discrepancies

  • Quantity dispensed must match quantity prescribed

#90 is prescribed and the patient requests #30, document on the hardcopy. #30 is prescribed and the patient requests #90, you must obtain authorization from the prescriber and document on the hardcopy.

Red Flags and Common Discrepancies

  • ‘As Directed’/ UD/ PRN
  • Pharmacist must document, date and initial on prescription- max dose per day and

authorizing official

  • Sliding scale must be clarified
  • Missing DEA number on control prescriptions
  • Hard Copy and Telephonic prescriptions
  • Signature Logs
  • Date of Fill and Date Picked up
  • Reverse within 14 days if not picked up (10 days for some plans)
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Red Flags and Common Discrepancies

  • Filled before date written
  • CIIs
  • Updated refill requests
  • Incorrect date used as ‘date written’
  • Controls- max of 5 refills within 6 months of date written
  • Non-controls- No refills after 1 year from date written
  • Missing address of patient on CII
  • Missing signature on Fax authorizations
  • Missing supervising physician on e-scripts

Red Flags and Common Discrepancies

  • Incorrect Prescriber
  • Nurse Practitioner, Physician Assistant, NPI
  • Missing information on scripts transferred into pharmacy
  • Write ‘Transfer’ on the face of the prescription
  • Pharmacy information, RX number, Original Fill, Last Fill, # of refills authorized, # of refills

remaining, Pharmacists transferring in and out

  • Incorrect use of DAW
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Red Flags and Common Discrepancies

  • Missing information on telephonic prescriptions-
  • Date, Time, name of person calling, initials of pharmacist/intern taking the call
  • Mis-filled Prescriptions: incorrect medication, strength, quantity, refill
  • Be careful when generating prescriptions from previous fill
  • Changes to dose/quantity must be documented on original
  • Include changes, reason, who authorized, date, time
  • Suboxone/Subutex/Buprenorphine
  • Must include prescriber DEA and “X” Number

Red Flags and Common Discrepancies

  • Directions outside of the FDA guidelines

Inhaler- use 2 puffs 8 times per day

  • Unauthorized Refills

Document who authorized refills, date, time

  • Auto-refills not allowed- Refilling on the same day each month can be a

trigger

  • Billing an NDC not dispensed (Obsolete NDC)
  • Billing for a larger pack size if a smaller size would be sufficient

(Sig- 2 drops ou bid X 5 days 15 ml)

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Red Flags and Common Discrepancies

  • Patients with both Medicare Part B and Part D

Medicare Part B Billing:

Insulin used in a pump

  • Oral immunosuppressive drugs secondary to a Medicare-approved transplant
  • Oral antiemetic drugs for the first 48 hours after chemotherapy
  • Inhalation drugs delivered through a nebulizer with the service location being

the patient’s home

  • Diabetic testing supplies, such as blood glucose meters, test strips and lancets
  • Certain drugs administered in a home setting that require use of an infusion

pump, such as certain antifungal or antiviral drugs and pain medications

  • Flu and pneumonia vaccines

On-site Audit

  • Advance notice should be provided – 15 days
  • Be clear on what will be audited
  • Obtain BIN/PCN numbers applicable to audit
  • Review claims for high dollar items prior to audit
  • Proactively obtain documentation if necessary from prescriber
  • Prepare staff
  • Date of audit
  • Be courteous and professional during audit
  • Minimize interaction with auditor- Staff should not be answering questions
  • Be Present!!
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On-site Audit

  • Clear space for auditor in break room or empty office with electrical
  • utlet
  • Be courteous 
  • Only share claim information for that specific PBM/plan
  • Ask for an exit interview to review any discrepancies found
  • IMPORTANT!!! Respond within timeline
  • Initial response
  • Appeal
  • Grievance (CHECK PROVIDER MANUAL!)

On-site Audit

  • Submit documentation in an organized manner and per policy
  • Cover Sheet – clearly explain why there is no discrepancy or what

additional documentation is included.

  • Have someone review documentation before submitting to confirm

message is clear and follows all requirement

  • No telephone or computer generated prescriptions typically accepted
  • Physician statement
  • Attestation from patient
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Attestation From Patient

  • I, ________, received RX #_____ filled on ________ and picked it up
  • n ___________ from ______________ Pharmacy.
  • You have permission to contact me via mail or phone if necessary.
  • Patient Name
  • Address
  • Phone
  • Email (if applicable)
  • _________________________________________ (signature)
  • ______________________(Date signed)

Desk Audit

  • Submit clear/legible documentation
  • Follow documentation requirements- Very specific per PBM
  • Review information prior to sending
  • Keep a copy of all information submitted, date and confirmation of receipt
  • Confirm receipt:
  • Fax confirmation (verify number of pages received)
  • Call to verify information is legible
  • Mail- proof of delivery
  • Never send original prescriptions
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Desk Audit

  • Invoice audits are increasing!
  • Pharmacies are being terminated if

billing an NDC not purchased

  • Bill the exact NDC dispensed!

Supporting Documentation Tips

  • Deadlines and guidelines for submitting documentation are essential
  • Request for an extension if needed
  • “No Post Audit Documentation Accepted”
  • Appeal if disagree regardless of discrepancy!!
  • Copy and track all documentation submitted and received
  • Create a folder for all correspondence
  • Mark your calendar to track results
  • Consult Legal Counsel when necessary
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How to Protect Your Bottom Line

  • Self-audit especially if not in the pharmacy every day
  • High dollar/expensive medications
  • Day Supply- Insulin, Test Strips
  • Compounds
  • Use Pre and Post Edits
  • PBM Provider Manuals (obtain from PSAO)
  • Use resources available for prevention and audit assistance
  • (Wholesaler/PSAO/Pharmacy Management System/Vendors)
  • Retain records for 5 years for most commercial plans and 10 years for

Medicare *Prescriptions and signature logs

How to Protect Your Bottom Line

Train and educate staff- Proper policy and procedures will ensure low recoupments

Train and educate

Review results with staff following an audit

Review

Use discrepancies as recommendations for improvement

Use

Reward for no discrepancies post audit

Reward

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Pharmacy Audit Bill of Rights

  • Specific to State
  • Examples:
  • No recoupment for clerical errors
  • No onsite audits within first 7 days of calendar month
  • Timelines for initial and final audit reports
  • Must give 14 days notice before onsite
  • List of claims to be audited with final 2 digits omitted
  • Period covered should not exceed 2 years

Active Learning

True or False:

  • 1. In general, PBMs are very flexible with the dates and deadlines.

If the documentation is due on 10/30/2018 and you submit documentation on 11/4/2018, they will most likely accept it. False- There are circumstances when extensions may be granted but this should be obtained in writing and not requested the day prior to due date.

  • 2. Prescriptions for patients who use insulin based on a sliding

scale are invalid. False- The prescription is valid. However, the max units per day must be documented on the prescription.

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Amanda Gaddy, R.Ph. agaddy@gpha.org

Questions?

Sources consulted

  • https://www.cga.ct.gov/2018/rpt/pdf/2018-R-0083.pdf
  • http://wvpharmacy.org/2017/12/pharmacy-audit-integrity-act-

enacted-into-law/

  • https://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_11.htm
  • Information obtained from experience working with pharmacies

impacted by audits

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