Audited by PBM, need some advice

[Doctor M]

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Today, We were audited by a PBM and so far my partner has said they have hit us with 8 oxycontin prescriptions for #120 each for not being on tamper proof pad. They say it was computer generated. I have been searching for the Tamper proof pad law and when it took effect. I do not see how they can rescind payment on a prescription on a technicality. It was not Fraud, merely a technicality. Todays audits are based on technicalities and not fraud, waste and abuse. Any body have any suggestions on how to fight this. On those 8 prescriptions alone, we are looking at a $12000 hit. Robbery since i already dispensed the damn drug. Any insight and suggestions would be great.

 

[Old Timer]

Today, We were audited by a PBM and so far my partner has said they have hit us with 8 oxycontin prescriptions for #120 each for not being on tamper proof pad. They say it was computer generated. I have been searching for the Tamper proof pad law and when it took effect. I do not see how they can rescind payment on a prescription on a technicality. It was not Fraud, merely a technicality. Todays audits are based on technicalities and not fraud, waste and abuse. Any body have any suggestions on how to fight this. On those 8 prescriptions alone, we are looking at a $12000 hit. Robbery since i already dispensed the damn drug. Any insight and suggestions would be great.

Welcome to the real world. You need to see if the prescription complied with the tamper proof law. Unless this is a Medicaid or Medicare rx, or Florida has their own law, it only applies to Medicaid/Medicare rxs,,,,

 

[Doctor M]

Welcome to the real world. You need to see if the prescription complied with the tamper proof law. Unless this is a Medicaid or Medicare rx, or Florida has their own law, it only applies to Medicaid/Medicare rxs,,,,

Why Can't I find any law that stipulates Medicare? I only see the law that stipulates Medicaid Recipients. The PBM is a Medicare Provider. I know of the Medicaid Law, but do not see one for Medicare.

 

[Old Timer]

Why Can't I find any law that stipulates Medicare? I only see the law that stipulates Medicaid Recipients. The PBM is a Medicare Provider. I know of the Medicaid Law, but do not see one for Medicare.

It does apply to Medicare. Google is your friend. It will get you to the CMS website.

 

[Doctor M]

It does apply to Medicare. Google is your friend. It will get you to the CMS website.

Google is my life.

 

[Doctor M]

It does apply to Medicare. Google is your friend. It will get you to the CMS website.

I must be a fool...Please show me where this law applies to Medicare. I see laws where States have to comply by April 2008...

 

[Old Timer]

I must be a fool...Please show me where this law applies to Medicare. I see laws where States have to comply by April 2008...

http://www.cms.gov/

 

[Doctor M]

http://www.cms.gov/

Not the CMS website Oldtimer, the law itself. It is implied that Medicare and Medicaid are one entity?

 

[psychoandy]

I'm a retail noob. Do you have specific contracts with said PBM, and is there anything in it that mentions following CMS / Florida Medicaid rules? And were these rx's from before the state law requiring tamper proof pads by July?

 

[farmadiazepine]

also a total noob here when it comes to audits, but can't you get an Rx rewritten by the MD on whatever pad you need with the correct date, so to satisfy all the requirements of the PBM? ..

.. is that allowed?

OR if it isn't, can't you do that anyway then just tell the PBM you finally found the Rx hidden somewhere

 

[Doctor M]

The PBM said there was nothing that cold be done. Total 100% charge back. The law took effect when? July? what year?

 

[Doctor M]

Not only did this audit take place, we were visited my AHCA (Medicaid on Tuesday) and have another audit by another PBM coming up. Overkill??

 

[All4MyDaughter]

The PBM said there was nothing that cold be done. Total 100% charge back. The law took effect when? July? what year?

Looks like last summer - http://doh.state.fl.us/MQA/padvendor_faq.html

 

[museabuse]

Wow that totally sucks. Damn, the pbms are going to go to town with that one. They really should fine doctors for not complying. Now I wish my state had a standard c2 prescription pad. I remember when the law came out but I don't know any pharmacist that follows it. I bet the pbm know which doctors do not comply with the law and audit those rxs, without even mentioning anything to the doctor.

 

[Doctor M]

Looks like last summer - http://doh.state.fl.us/MQA/padvendor_faq.html

that is a state Law for July 2011. These Prescriptions were from 2010. The law would not have applied. Also, Im still looking for the law that states the tamper proof law is for Medicare recipients. I only see where it says it is for Medicaid Recipents.

 

[Its Z]

that is a state Law for July 2011. These Prescriptions were from 2010. The law would not have applied. Also, Im still looking for the law that states the tamper proof law is for Medicare recipients. I only see where it says it is for Medicaid Recipents.

Have the pbm provide the dated regulation.....like tell them you will fully cooperate so show me the document or the mandate. They need show you what you violated.

 

[Sparda29]

Thank God for New York having the standard prescription pads for all.

 

[lorain]

you folks better get used to it

when you have ridicolously priced drugs like acthar costing 24K per vial, the plans want to make their money up in other ways

auditing will only increase

 

[Doctor M]

Have the pbm provide the dated regulation.....like tell them you will fully cooperate so show me the document or the mandate. They need show you what you violated.

I still cannot find the Medicare Law that stipulates Medicare D recipients need tamper proof pads. I see the CMS ruling for Medicaid recipients. I was under the impression that Medicare and Medicaid are different.

https://www.cms.gov/FraudAbuseforProfs/downloads/trpupdatedfaqs.pdf

 

[Farmercyst]

Today, We were audited by a PBM and so far my partner has said they have hit us with 8 oxycontin prescriptions for #120 each for not being on tamper proof pad. They say it was computer generated. I have been searching for the Tamper proof pad law and when it took effect. I do not see how they can rescind payment on a prescription on a technicality. It was not Fraud, merely a technicality. Todays audits are based on technicalities and not fraud, waste and abuse. Any body have any suggestions on how to fight this. On those 8 prescriptions alone, we are looking at a $12000 hit. Robbery since i already dispensed the damn drug. Any insight and suggestions would be great.

Would this help? http://www.ncpdp.org/public_documents.aspx#trpp

Tamper-Resistant Prescription Pads

On June 26, 2008, the National Council for Prescription Drug Programs (NCPDP) held a second industry forum in an effort to review the implementation of the first phase of the CMS tamper-resistant regulations and to discuss next steps necessary to ensure a smooth transition into the second phase of implementation on October 1. As a result of this meeting, industry standards for copy, erasure/modification, and counterfeit resistance have been clarified. Also, CMS had previously stated that prescriptions printed from EMRs or ePrescribing applications would likely need special copy resistant paper to be in compliance as of October 1, 2008. CMS is now clarifying that guidance, based on its awareness of improved printing capabilities, and is now stating that while special paper may be used to achieve copy resistance, it is not a requirement. EMR or ePrescribing generated prescriptions may be printed on plain paper and be fully compliant with all three categories of the tamper-resistant regulations provided they contain at least one feature from each of the three categories.

The attached letter recommends best practices developed by the industry forum and is strongly suggested for adoption in order to meet the tamper-resistant requirements.

In addition to this guidance, we have created a template letter for you to use when communicating this information to your prescriber community. You are encouraged to modify this letter with your state specific requirements.

Current Florida law seems to allow computer generated rxs aslong as it meets legal requirement. Though this seems to have taken effect last July, so I'm not sure what the law was prior to that.
http://www.doh.state.fl.us/mqa/padvendor_faq.html#Pharmacists

 

[Doctor M]

Would this help? http://www.ncpdp.org/public_documents.aspx#trpp


Current Florida law seems to allow computer generated rxs aslong as it meets legal requirement. Though this seems to have taken effect last July, so I'm not sure what the law was prior to that.
http://www.doh.state.fl.us/mqa/padvendor_faq.html#Pharmacists

It still doesnt tell me about Medicare Recipients. All the Literature is about Medicaid Patients. I guess I am to assume they are treated as one? Either way, we will contest these ludicrous charge backs.

 

[All4MyDaughter]

It still doesnt tell me about Medicare Recipients. All the Literature is about Medicaid Patients. I guess I am to assume they are treated as one? Either way, we will contest these ludicrous charge backs.

I think Z's advice was sound. Ask the PBM to show you precisely what law/statute/contract clause you are in violation of. Make them demonstrate that it was in force at the time of filling.

 

[Doctor M]

I think Z's advice was sound. Ask the PBM to show you precisely what law/statute/contract clause you are in violation of. Make them demonstrate that it was in force at the time of filling.

We will do that. Thank you all for your advice and responses.

 

[All4MyDaughter]

We will do that. Thank you all for your advice and responses.

Give them hell!!

 

[Farmercyst]

If they're using this, then "may" seems pretty key. Especially since the link indicates a proposed rule change to make it mandatory. (meaning it's not mandatory already.)
https://www.flrules.org/gateway/RuleNo.asp?id=64B-3.005
Another possibility would be it's in your contract, not statute.

 

[Doctor M]

If they're using this, then "may" seems pretty key. Especially since the link indicates a proposed rule change to make it mandatory. (meaning it's not mandatory already.)
https://www.flrules.org/gateway/RuleNo.asp?id=64B-3.005
Another possibility would be it's in your contract, not statute.

I have never seen our contract. The PBM is part of our buying group who contracts us with them. Also, the auditor said he was obligated to watch our technician pull the scripts. Not that we had anything to hide, just seems a bit weird...

 

[kvl1027]

I have never seen our contract. The PBM is part of our buying group who contracts us with them. Also, the auditor said he was obligated to watch our technician pull the scripts. Not that we had anything to hide, just seems a bit weird...

M, get with your Cardinal rep and have them connect you to Cardinal's audit assitance. Also, I would talk to Your API guy as well, API has some people that can help. Good luck, this is a pretty big burn and worth the fight. Let me know how it goes.

 

[Doctor M]

M, get with your Cardinal rep and have them connect you to Cardinal's audit assitance. Also, I would talk to Your API guy as well, API has some people that can help. Good luck, this is a pretty big burn and worth the fight. Let me know how it goes.

I submitted all paperwork and they retracted their stance on that chargeback!🙂 However, they violated the law below by not giving us the time frame to contest a chargeback as required by Florida Law. We have forwarded them a copy of the law and await to hear their response!

http://www.leg.state.fl.us/Statutes...g=&URL=0600-0699/0641/Sections/0641.3155.html

 

[MountainPharmD]

I submitted all paperwork and they retracted their stance on that chargeback!🙂 However, they violated the law below by not giving us the time frame to contest a chargeback as required by Florida Law. We have forwarded them a copy of the law and await to hear their response!

http://www.leg.state.fl.us/Statutes...g=&URL=0600-0699/0641/Sections/0641.3155.html

Sweet so you get to keep the 12k!

I may work for a PBM but I have nothing to do with chicken **** crap like this.

 

[Its Z]

I submitted all paperwork and they retracted their stance on that chargeback!🙂 However, they violated the law below by not giving us the time frame to contest a chargeback as required by Florida Law. We have forwarded them a copy of the law and await to hear their response!

http://www.leg.state.fl.us/Statutes...g=&URL=0600-0699/0641/Sections/0641.3155.html

Awesome I see you took my advice based on my deciphering of the reg!

 

[Doctor M]

Sweet so you get to keep the 12k!

I may work for a PBM but I have nothing to do with chicken **** crap like this.

the initial charge back was $37500. The final charge back was $9000 but they illegally did this because they did not give us an appeal process. We get 35 days according to the law. We are now appealing but i dont know if there are statute of limitations.

 

[Doctor M]

Awesome I see you took my advice based on my deciphering of the reg!

👍 Yes sir!

 

[kvl1027]

I submitted all paperwork and they retracted their stance on that chargeback!🙂 However, they violated the law below by not giving us the time frame to contest a chargeback as required by Florida Law. We have forwarded them a copy of the law and await to hear their response!

http://www.leg.state.fl.us/Statutes...g=&URL=0600-0699/0641/Sections/0641.3155.html

That's awesome, glad to hear it. Check 1 for the independents.

 

[Doctor M]

Got a call from another PBM yesterday and since we challenged their findings on some claims with the wrong physicians on narcotics, they are gonna forgive the errors and not recoup the money. Any independent out there needs to know the law and do what they can to prevent any chargebacks. This was a total win for us. The chargeback went form $15,000 to $1500 to $500. I assume the PBM did not want to prolong the fight over $1000. Either way, we know now how to protect ourselves. The PBM stated that a wrong Physician was a reversible claim per Medicare D laws. I will look for this law and read into this.

 

[MountainPharmD]

Got a call from another PBM yesterday and since we challenged their findings on some claims with the wrong physicians on narcotics, they are gonna forgive the errors and not recoup the money. Any independent out there needs to know the law and do what they can to prevent any chargebacks. This was a total win for us. The chargeback went form $15,000 to $1500 to $500. I assume the PBM did not want to prolong the fight over $1000. Either way, we know now how to protect ourselves. The PBM stated that a wrong Physician was a reversible claim per Medicare D laws. I will look for this law and read into this.

Fight the man!

 

[Doctor M]

Humana audit in one month. 🙂