Adjusting Quantity or Days’ Supply Disproportionately Will Cost You!
PAAS National® wants to emphasize the importance of submitting the correct days’ supply on claims. We see many audit results that could have been avoided had the pharmacy addressed the initial rejection and not bypassed the plan limit. A prevention strategy is important because these discrepancies are often difficult to appeal successfully. Pharmacy employees should be taught that a paid claim [at adjudication] may not remain paid [upon audit] and is no substitute for a claim that is billed accurately.
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Plan limit rejections are intended to help control costs, provide clinical edits, and assist pharmacies in ensuring patient safety. When you bill a claim for the calculated days’ supply [based on the quantity and directions] and receive a rejection, you must identify and address the underlying rejection message. Paying attention to these rejection messages is key to avoiding audit recoupments. Here are a few examples:
- “Exceeds maximum daily dose, prior authorization required”
Prescription: Insulin Aspart FlexPen, 45 mL
Sig: Inject 40 units before breakfast, lunch, and supper plus correction scale. Max daily dose of 185 units.
Days’ Supply Calculation: 4500 units/185 units per day = 24 days’ supply
Initial Rejection with accurate days’ supply: “Exceeds maximum daily dose, prior authorization required”
Pharmacy Action: Rebilled the days’ supply for 30.
Audit Discrepancy: The claim was flagged as an incorrect days’ supply indicating a prior authorization (PA) is required for the dose prescribed
Potential Recoupment: full claim amount
Recommended Action Upon Initial Rejection: pursue prior authorization. Most limits are based on typical clinical use and/or FDA approved dosing.
- “Plan limit exceeded”
Prescription: Oxycontin 80 mg, #90 tablets
Sig: One tablet three times a day
Days’ Supply Calculation: 90 tablets/3 tablets per day = 30 days’ supply
Initial Rejection with accurate days’ supply: “Plan limit exceeded. Maximum two tablets per day.”
Pharmacy Action: Rebilled the claim for #60 for 30 days
Audit Discrepancy: The claim was flagged as an incorrect days’ supply indicating a prior authorization (PA) is required for the dose prescribed
Potential Recoupment: full claim amount
Recommended Action Upon Initial Rejection: pursue prior authorization. Bypassing these edits for opioids can lead to overdoses or diversion. Especially for controlled substances, pharmacists have a corresponding responsibility to ensure that prescriptions are for a legitimate medical purpose 21 CFR 1306.04(a). The prescriber should obtain a prior authorization, change the dose or prescribe an alternative medication.
While we have recently seen OptumRx® be more aggressive with pharmacies “willfully” bypassing plan limits, all PBMs can easily identify when a claim rejected and was then immediately rebilled for the same quantity but different days’ supply or different quantity but same days’ supply (i.e., the quantity/day ratio change from the initial adjudication to a subsequent adjudication). This raises a red flag and is an easy audit target for PBMs.
PAAS Tips:
- Always bill for the accurate days’ supply based on the quantity and the directions given on the prescription
- Educate all pharmacy staff to identify rejection messages, how to properly resolve them, and avoid inputting an incorrect days’ supply or quantity to get a paid claim
- Check with the PBM help desk for guidance on rejects that are vague or unclear
- Do not split bill rejected claims
- Charging the patient cash often leads to complaints (from the patient to an employer or PBM) and can be considered non-compliance with the provider manual and lead to remediation, cease and desist letters, or even network termination
- If you have exhausted all plan options (including pursuing a PA or alternative therapy) and the patient insists on paying cash for the full prescription, be sure that you document authorization from the patient that they desired to pay the full cost and did not want to wait for the proper channels, and they will not seek reimbursement from the insurance
- If the prescriber does not follow through on obtaining a PA, enlist the patient to help. The patient could contact the prescriber and/or file a complaint with their insurance which may speed up the process
- See the following Newsline articles for more information on claim rejections
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
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- Adjusting Quantity or Days’ Supply Disproportionately Will Cost You! - December 24, 2024
