Insurance audits

[tompharm]

---

Members don't see this ad.

what are some reasons insurance audits a prescription. Or what can I do as a pharmacist to prevent it.

 

[zelman]

You can't really prevent an audit. They will happen periodically. The Rx's they look at tend to be higher cost and/or unusually short day supply's.

 

[Sparda29]

How are they about compounds? A lot of our customers were complaining that their 30 g creams were only lasting 1 week if used BID and the 60 g creams were only lasting 2 weeks if used BID. Called the doctor and told him to just prescribe 120 g by default. He okayed it but occasionally forgets to write quantities. If I were to just note something like, "as per discussion with Dr. X, dispense 120 g" on all of the compound scripts, could that have a problem?

 

[Old Timer]

Here is what auditors look for:

• Obvious dosing errors such as 3 packs of oral contraceptives with a 28 day supply.
• Drugs that require extra documentation such as Accutane and Lotronex.
  
• Expensive drugs.
• Billing for the wrong package size. Bill for 2x15 gm tube of drug x instead of 1 x 30 gm.
• You billed for the correct number of refills.
• You billed for the correct doctor.
• You billed the correct DAW code based on the documentation on the hard copy.
• You billed the correct origin code on a Medicare D claim.
• You have the proper documentation on a Medicare B claim.
• You actually can produce the hard copy at audit.
• You billed for the correct drug.

 

[kvl1027]

The best way to avoid an audit is to be CVS.....😉

 

[Old Timer]

The best way to avoid an audit is to be CVS.....😉

Shows how far your head is up your nether regions. I work at CVS and we get audited all the time. Shows how much you know......

 

[Sparda29]

Do faxed in prescriptions need to have the date and time stamp and origin? The doc here tends to put the prescription in the middle of his fax scanner rather than on a corner. I was told that when filing that I should keep that entire paper intact and just fold it rather then cutting out the prescription part and throwing out the edges.

 

[farmadiazepine]

Keep the whole paper. Make sure you have where it's coming from as well as who it's going to. Make sure it's signed too. We change a lot of faces to telephone because there are so many things missing that insurances try to audit.

 

[Prepharm1214]

DAW codes are big if not documented correctly
Day supply/boxes of insulin given
Not documenting "number of headache days" on triptans
Anything billed to express scripts/medco

 

[Sparda29]

Keep the whole paper. Make sure you have where it's coming from as well as who it's going to. Make sure it's signed too. We change a lot of faces to telephone because there are so many things missing that insurances try to audit.

Odd, the owner of this independent keeps telling me to avoid taking telephone Rxs for compounds.

 

[kvl1027]

Shows how far your head is up your nether regions. I work at CVS and we get audited all the time. Shows how much you know......

No need to get sassy! How often does CVS/Caremark audit you? CVS/Caremark has a hard-on for auditing independents, I'm sure they audit their own stores just as much.....you know, to be fair.

 

[kvl1027]

Odd, the owner of this independent keeps telling me to avoid taking telephone Rxs for compounds.

Did he give a reason for that? I've never had an issue because a script was a telephone order.

 

[Sparda29]

No need to get sassy! How often does CVS/Caremark audit you? CVS/Caremark has a hard-on for auditing independents, I'm sure they audit their own stores just as much.....you know, to be fair.

I just got a fax from CVS/Caremark yesterday that was supposed to be an informational about how to bill topicals. Apparently now they are calculating how long a quantity should last a patient. Apparently they came up with this thing called fingertip units.

For example, doctor writes for 400 gm of a topical to be used BID. They don't want us to just dispense 400 gm, they want us to calculate based on their chart how much to give and reduce the amount or get documentation from the doctor that it is for a large area. This dermatologist I work with regularly just writes apply as directed bid. That's not good enough anymore apparently.

 

[Ackj]

I just got a fax from CVS/Caremark yesterday that was supposed to be an informational about how to bill topicals. Apparently now they are calculating how long a quantity should last a patient. Apparently they came up with this thing called fingertip units.

For example, doctor writes for 400 gm of a topical to be used BID. They don't want us to just dispense 400 gm, they want us to calculate based on their chart how much to give and reduce the amount or get documentation from the doctor that it is for a large area. This dermatologist I work with regularly just writes apply as directed bid. That's not good enough anymore apparently.

Interesting. I typically go 1 gram/ dose without further information. So 15g qd or 30g bid would both be 15 days. But yes, you do get the cases where they come back in 4 days because they were covering a large area, and then you have to get a refill too soon override.

 

[Sparda29]

Interesting. I typically go 1 gram/ dose without further information. So 15g qd or 30g bid would both be 15 days. But yes, you do get the cases where they come back in 4 days because they were covering a large area, and then you have to get a refill too soon override.

Our most popular compound is the desonide tretinoin hydroquinone compound and from I've been told it goes all over the face and neck.

 

[BenJammin]

Here is what auditors look for:

• Obvious dosing errors such as 3 packs of oral contraceptives with a 28 day supply.
• Drugs that require extra documentation such as Accutane and Lotronex.
  
• Expensive drugs.
• Billing for the wrong package size. Bill for 2x15 gm tube of drug x instead of 1 x 30 gm.
• You billed for the correct number of refills.
• You billed for the correct doctor.
• You billed the correct DAW code based on the documentation on the hard copy.
• You billed the correct origin code on a Medicare D claim.
• You have the proper documentation on a Medicare B claim.
• You actually can produce the hard copy at audit.
• You billed for the correct drug.

Independent I do part time work with has never lost money doing this. They DO lose money by not breaking insulin pens though...

 

[kvl1027]

Our most popular compound is the desonide tretinoin hydroquinone compound and from I've been told it goes all over the face and neck.

Interesting how they have the oversight come up with numbers that covers all of the variations in application and treatment that patients would experience.