Keeping the Audit Hounds at Bay

Ways to Successfully Prevent and Ace an Audit

Disclosure Statement

Eileen Fournier & Kathy McIntyre

Presenters have no conflict of interest to disclose

Speaker’s presentation of this slide indicates agreement to abide by the non-commercialism guidelines provided in the CE Requirements page

The information provided in this presentation is true and accurate to the best of our combined experience and knowledge

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Oh no! Not another

audit!

Have you ever thought this when Corporate sends you another notice that your pharmacy will be audited soon?

What products are most audited?

And more importantly how can you avoid or pass the audit when it comes?

What triggers those audits?

Audit Triggers…

Quantity and Day Supply…

Overbilled quantity is the biggest offender in audits

What is an overbilled quantity?

Quantity billed exceeds the amount authorized by the

prescriber, or

Quantity dispensed exceeds the day supply submitted, or

Quantity exceeds what the plan allows

What products are big offenders?

Topical medications (creams / ointments)

Ear / Eye drops

Triptans

Insulin

Expensive kits like Humira, Copaxone, etc.

Use as Directed…

‘Use as directed’ SIGs are another dangerous avenue

What forms can a ‘use as directed’ SIG take?

‘Per sliding scale dose’

‘As needed for migraine’

‘Per prescriber’s orders’

Ways to combat the dreaded ‘Use as Directed’ SIG…

Contact the prescriber for complete instructions

Ask the patient

(be careful to document information from the patient away

from the prescriber’s SIG and do not type it on the label)

Getting a max dose per day from either the prescriber or

patient

UAD

True or False…

When the patient gives you the max dose or area to be treated it’s best to include that information in the SIG.

FALSE

The BIG offenders…

Details on ways to figure out day supplies when filling these products…

Topicals – creams / ointments

Ask the prescriber or patient for area or size of

area

Use the fingertip unit to determine the day supply

Look at patient filling history

Always use the smallest size available

What is the fingertip unit?

From the tip of your index finger to the first joint is considered 1 fingertip unit

Now it‘s your turn…

Measure out 1 fingertip unit & apply it to your hand…

Does that amount cover the front and back of your hand?

Ear & Eye Drops…

15 to 20 drops per ml is the standard range

Some insurances will allow 15 drops per ml to allow for

human error

Always dispense the smallest size bottle available

For emergency prescriptions that the patient must start right

away:

If you only have a large size bottle document that the patient

could not wait for a smaller size to be ordered on the hard copy

Show me the math…

Prescription reads as follows:

Drug: PREDNISOLONE AC 1% EYE DROP

SIG: INSTILL 1 DROP INTO BOTH EYES 4 TIMES DAILY

Order Quantity: 5ml

What would the day supply be?

Answer…

5ml

X 15 drops

75 total drops

And…

1 drop into each eye

X 4 times daily

8 total drops per day

So…

75 / 8 =

9.375 or 9 day supply

True or False…

The easiest way to determine a day supply for an ear or eye drop is to use the fingertip unit method.

FALSE

Triptans…

Easy target for auditors

Most insurance companies look to the drug manufacturers for

dosing guidelines.

4 headaches in a month is the typical guideline for these

medications

Package inserts will state, “The safety of treating an

average of more than 4 headaches in a 30 – day period has

not been established” (

Imitrex Package (GSK) Insert 2.1 ‘Dosing Information’)

Billing for 4 migraine episodes in a 28 day period is a good rule

of thumb

What to do if the patient has more than 4 migraines in a 28 day period…

Document how many headaches the patient suffers from monthly

From the patient

From the prescrib

er

The insurance may also require a prior authorization

Insulin…

Use as directed type SIGs are very common for

insulin

Remember

a sliding scale SIG does not give enough information

Asking for the max daily units will help determine the

day supply

Questions to ask when calculating the day supply:

How many total units are in a vial or pen?

How many total units is the patient using daily?

How long will the vial or pen last once it has been

opened?

Multiple Choice…

A prescription comes in for 3 vials of insulin with the directions of ‘use per sliding scale directions’. How should you calculate the day supply?

a) Use a 30 day supply as this is the max day supply the insurance

will allow

b) Consult the magic 8 ball you have on hand at all times

c) Only dispense 1 vial for a 28 day supply

d) Contact the prescriber or ask the patient for their max daily units

and calculate the day supply using that information.

D

Expensive Kits Make for Easy Targets…

Humira

Copaxone

Enbrel

Make sure you are billing the correct pack size…

Look carefully at the way your computer

system has the pack size set up for each

kit.

If you are unsure if it is set for the

whole kit or single dose compare it to

your supplier invoice.

Make sure you are billing the correct day

supply

Example:

Copaxone kit normal dosing used to be billed

as quantity 1 for a 30 day supply

Now normal dosing is billed as a quantity of

30 for a 30 day supply.

Watch out for loading doses…

Make sure you take in account the loading

dose on the first fill and remember not to

include it on subsequent fills

Vagifem - another medication with a

loading dose that often is billed

incorrectly on subsequent fills

Create 2 prescriptions

1 for the first month or fill which

includes the loading dose with no refills

Another for the refills for the

continuation of therapy

Other Third Party Findings…

Early Refill / Refill Too Soon Overrides…

Document the reason for the refill

too soon override

For vacation override

Date of departure

Date of return

Lost or stolen medication

Copy of police report may be

required

DAW codes… Make sure you are using the correct DAW code

Document on the hard copy reason for DAW code being used

How many use a DAW 9 when billing OR Medicaid?

http://www.oregon.gov/OHA/healthplan/pages/pdl.aspx

X – DEA #...

Is it being used for pain or opiate addiction?

Do you have the X-DEA # written on the hardcopy if it’s for opiate addiction?

Do you have “for pain” in the SIG if it’s not for opiate addiction?

Isotretinoin Prescriptions…

Make sure you have on the

hard copy

The RMA #

And the pick up by date

RMA # 12345678911

P/U by 11/1/2014

And finally the best advice we can give is…

Document!

Document!

Document!

Document!

Document!

Preparing for a Successful Audit…

There are several important things to remember

and consider when you are preparing for an audit:

Make sure that all licensing is current and

displayed.

Pharmacist and Technician Licenses

State Board License

DEA License

The auditor should provide you with a date range

at the time you receive your audit notification of

the claims that will be review.

Make sure that all prescriptions are available in store

for the date range given

Some auditors, but not all, may provide a masked list

prior to the audit date.

However you file your hard copy prescriptions, make

sure that they are available for viewing.

It’s best to have your controlled substance

prescriptions copies readily available.

Some auditors seem to be ok viewing the non-

controlled prescriptions in the computer system.

Make sure to schedule a HIPAA trained staff

member to help assist the auditor during the

audit.

This can make your audit go smoother and faster.

It also allows quicker responses if the auditor is

requesting additional documentation as in:

notes in the patient files,

pulling prescriptions copies

printing screen prints

It’s good to provide extra space in your pharmacy,

such as a back counter, so that the auditor has room

to work.

Verify who is entering your pharmacy

Check their ID badge

Have them sign in and out of your pharmacy per

HIPAA regulations

You may be asked additional questions during or

at the end of audit, such as:

Policy and procedure questions (i.e. return to stocks)

Staff training for HIPAA and FWA

The auditor may want to go over their findings,

discrepancies with the pharmacist.

Ask questions…

This is a great time to pick the brain of an auditor

And be sure to share what you learned during the

audit with your team!

RELAX!

And above all…