PBMs Are Criticizing Clinical Notes!

Calling a prescriber’s office due to a prescription with missing elements, or needing clarification, is an inescapable task. If you are failing to document that phone call with a valid clinical note, PBMs may flag the claim upon audit and try to recoup. We have seen OptumRx, Humana, Navitus, and ESI/Prime results citing pharmacy clinical notes. Many of the provider manuals have language on what a valid clinical note should minimally contain. Our experience upon reviewing audit documents, results, and provider manuals is that a clinical note should contain four elements. If the following elements for a clinical note are present, they will reduce an auditor’s ability to recoup upon audit.

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PAAS National® recommends these four elements be attached to all clinical notes:

  1. Date/Time of the call/conversation
  2. Name and title of who you spoke with
  3. Specific details about the clarification
  4. Initials or name of the pharmacy employee making the clarification

PAAS Tips:

  • Clinical notes are part of the pharmacy record and must be provided upon any audit
  • Train staff and have a policy on how clinical notes will be documented
  • Some pharmacies have created a customized ink stamp to aid in the documentation process
  • Check with your software vendor on how to utilize the electronic notes field
    • Date/time stamped notes provide validation to the PBM that they existed at the time of dispensing
    • Humana requires a copy of pharmacy electronically stored notes for various discrepancies
  • If you are making handwritten clinical notes, be sure to rescan the prescription into your software
  • Annotations made on previous prescriptions may be carried forward to a new prescription (where relevant) if clinically appropriate based on a pharmacist’s professional judgement
  • If the patient instructions are clarified, ensure the patient label is updated prior to dispensing to reflect the new directions
  • Some provider manuals have language indicating “per MD” is not acceptable (need the name and title of who you spoke with)
  • Remember the saying, “if it isn’t documented, it didn’t happen”
  • See these Newsline articles for additional tips:

Jennifer Ottman, CPhT
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