The Audit Adviser: Quantity Changes Cause Audit Appeal Trouble
Content provided by Trenton Thiede, PharmD, MBA, president at PAAS National. Original article found on America's Pharmacist, page 11 (2023 October).
PAAS National is seeing more discrepancies for “unauthorized” refills on audits and PBMs continue to make these discrepancies difficult to appeal. For example, Humana only allows electronically stored date and time stamped pharmacy notes validating the increase in quantity and/or refills (and the date authorized). Similarly, OptumRx will only accept a prescriber statement on appeal for unauthorized refills if the causality is not an undocumented/unapproved increase in quantity.
What is considered an “unauthorized refill?”
Dispensing a quantity larger than written without documented prescriber approval.
If a prescriber writes for 3 mL on an insulin pen, you cannot simply increase the quantity to 15 mL to dispense a full box.
In states where consolidating refills without prescriber approval is allowed, you cannot dispense more than the total original quantity and refills written without consulting with the prescriber.
If a prescriber writes for 3 mL plus two refills on an insulin pen, you can only dispense 9 mL total without consultation with the prescriber.
Transfer prescriptions need to be entered carefully. Pay close attention to “total refills remaining” versus “1+x refills remaining.”
Pay attention to electronic prescription fields of “authorized fills” versus “refills.”
Having a clear unit of measure on a written quantity prevents confusion.
If a prescriber writes for 15 “unspecified” for a quantity on an insulin pen, an auditor may argue it is unclear if the prescriber meant 15 mL, 15 pens, or 15 boxes.
If a prescriber writes for a quantity of “1” on inhalers, topical medications, or eye drops, the auditor will assume the smallest package size even if that is an institutional size pack not regularly dispensed by retail pharmacies.
If a prescriber writes “one month for a quantity, ensure your days’ supply is NOT more than 30 days. For example, an insulin pen written for 45 units daily and a one-month supply has an actual days’ supply of 33, not 30. This quantity should be clarified to ensure over-dispensing does not occur.
In all the above cases, good documentation is key to avoiding audit discrepancies. It is preferable to have date and time stamped electronic notes at the time of dispensing. Check with your software vendor about your system’s capabilities.
Ensure documentation is consistent and thorough when handling quantity changes.
Clarify any ambiguous quantities or unspecified units of measure with the prescriber.
Be sure your transferred prescription refills are entered appropriately.
Understand the nuances of refill wording and how this can affect claims.
When contacting the prescriber about changing or clarifying quantities or refills, be sure you document the prescription with a complete clinical note.
A complete clinical note includes the date, name and title of who you spoke with, summary of what was discussed, and pharmacy employee initials.
Trenton Thiede, PharmD, MBA, president at PAAS National, expert third party audit assistance and FWA/HIPAA compliance. For more information, call 608-873-1342 or visit PAASNational.com.