Ipratropium q4

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Curiousone1111

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hey. Rph filled ipratropium nebulization 0.5 mg (2.5ml vial) q4 for a kid. Standard dose is q6-8. Thats six times a day. No note about md being aware dose is high. Im refilling and dont want to proceed til i talk to the office. Thats one thing on its own

Second, when u go by the days supply according to 6x per day, it rejects saying max qty 11 ml (so 4 vials). They only pay for four times a day then. Rph has filled by changing days supply to a higher number to make it go thru. If the dr says they still want 6x per day and knows its high, Is this okay to make it go thru? Technically the pt will run out quicker if using as directed but in terms of insurance were still not able to rebill til those days pass even tho the sig frequency exceeds what they pay for, so it should be ok?

Idk if it would ever say “max qty 11. Need pa” if it said that then u need pa for any qty over 11 ml then i wouldnt want to extend days supply to make it go thru. But i dont think they mention pa for that so it should be okay to change the days to make it go thru cuz technically ur still dispensing a box which is what insurance will pay for every x days. Just wasnt sure if its an issue since the days supply doesnt match the sig frequency
 
I honestly cannot imagine checking refills this thoroughly. I think you check refills more thoroughly than I check new orders.

For your first part of the post: It's a refill. Has the patient been taking it as prescribed? Any side effects? When you call the office what concern exactly are you going to voice and what end result are you looking for? If you just want the MD to confirm that he knows the dose is high you are wasting his time and yours, IMO.

For the second part: Billing anything other than what the directs say is insurance fraud. Guess what, it happens every day in every pharmacy. Will they audit you and if they do will they care? Perhaps not. You as a pharmacist will not get in trouble for an RX that was mis-billed so I wouldn't worry about that part at all. The only part that sucks is that the patient won't be able to refill it as often as they like since it will be too soon. As long as the patient (or their parents, whatever) understands that you are golden.

IMO you need to learn the culture of your pharmacy and be consistent with your partner(s). If you are a floater I would suggest "going with the flow" more.
 
Haha, guess I belong in inpatient pharmacy 😉

NITRAS said:
I used to think inpatient pharmacist could get annoying. I’ll have to apologize next time I see them.

Darn, remind me to never go outpatient.
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You’re right, if anything it’s an audit and chargeback issue, but shouldn’t affect the rph’s license (unless you’re messing around with controls lol). I guess it just seemed off to me to change the days supply for the nebulization to make it go thru because it wouldn’t occur to me to do that for tablets.

If the directions are one tab bid #60 and ins says max 1 tab per day... if patient says I want whatever I can get, would u dispense #30 for 30 days? In the end the insurance is still paying for just one a day but it wont match the sig/frequency. Again, probably just an audit issue because the rx is still valid.

Thanks owlegrad for always giving solid advice 🙂

owlegrad said:
I honestly cannot imagine checking refills this thoroughly. I think you check refills more thoroughly than I check new orders.

For your first part of the post: It's a refill. Has the patient been taking it as prescribed? Any side effects? When you call the office what concern exactly are you going to voice and what end result are you looking for? If you just want the MD to confirm that he knows the dose is high you are wasting his time and yours, IMO.

For the second part: Billing anything other than what the directs say is insurance fraud. Guess what, it happens every day in every pharmacy. Will they audit you and if they do will they care? Perhaps not. You as a pharmacist will not get in trouble for an RX that was mis-billed so I wouldn't worry about that part at all. The only part that sucks is that the patient won't be able to refill it as often as they like since it will be too soon. As long as the patient (or their parents, whatever) understands that you are golden.

IMO you need to learn the culture of your pharmacy and be consistent with your partner(s). If you are a floater I would suggest "going with the flow" more.
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Curiousone1111 said:
You’re right, if anything it’s an audit and chargeback issue, but shouldn’t affect the rph’s license (unless you’re messing around with controls lol). I guess it just seemed off to me to change the days supply for the nebulization to make it go thru because it wouldn’t occur to me to do that for tablets.

If the directions are one tab bid #60 and ins says max 1 tab per day... if patient says I want whatever I can get, would u dispense #30 for 30 days? In the end the insurance is still paying for just one a day but it wont match the sig/frequency. Again, probably just an audit issue because the rx is still valid.

Thanks owlegrad for always giving solid advice 🙂
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Yes, although it will be the same problem in the end. The patient is going to come back in 15 days and want their refill and won't understand that it is too soon. "But they paid for it last time!"

Welcome to the fun of retail my friend.
 
Haha, as long as they understand they’ll run out soon!! Thanks 🙂


owlegrad said:
Yes, although it will be the same problem in the end. The patient is going to come back in 15 days and want their refill and won't understand that it is too soon. "But they paid for it last time!"

Welcome to the fun of retail my friend.
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Actually owlegrad, didn’t u say you should NOT do that in this thread by justjoe?

Is it proper to override high-dose DUR rejects by changing the day supply?

“But changing the days supply for tablets to something inaccurate just to get a paid claim? Of course that is insurance fraud. How would you describe deliberately inputting inaccurate information into a claim? I can see doing it for an inhaler or cream or anything that can't be broken down into a smaller unit, but for tablets? No way!”

owlegrad said:
Yes, although it will be the same problem in the end. The patient is going to come back in 15 days and want their refill and won't understand that it is too soon. "But they paid for it last time!"

Welcome to the fun of retail my friend.
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Generally If you get a hard stop for hd req a pa or cash out if pt wants to pay cash actually. Why risk discipline for a freaking rx. They can take it elsewhere.

On the other hand delay things too much and you will have to justfy why you dudnt call the pt, didnt follow up with the prescriber in a timely fashion etc. this is a problem esp with e scripts as you cant just give back the rx
 
Curiousone1111 said:
Actually owlegrad, didn’t u say you should NOT do that in this thread by justjoe?

Is it proper to override high-dose DUR rejects by changing the day supply?

“But changing the days supply for tablets to something inaccurate just to get a paid claim? Of course that is insurance fraud. How would you describe deliberately inputting inaccurate information into a claim? I can see doing it for an inhaler or cream or anything that can't be broken down into a smaller unit, but for tablets? No way!”
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You have exposed me for the hypocrite that I am. 😉
 
Lol! This post cracked me up on my lunch today! Way to overthink things!

I’ve always been taught and under the impression that insurance audit will only care about day supply if you’re giving a higher amount than what is normal for a day supply. Like an extreme case would be three advair inhalers billed for 30 days. Like duh.

But if you extend the day supply like in this example and the patient runs out early that’s more of a inconvience for the patient rather an audit issue for insurance. I was taught they wouldn’t really look at specific directions. Just quantity versus day supply. Like an example of this is ompreazole 40mg bid but u bill 90 for 90 days. At least the patient gets some but then you worry about the pa for next fill...sorta thing. 🙂
 
I've always thought there was no problem with increasing the amount of days supply (because the insurance will still pay for 4/day, even if the pt uses it 6/day and has to pay cash every other fill or so), the problem is decreasing the days supply (ie RX written for 4/day, but pt wants to use it 6/day, so RPH runs 180/30 days even though the RX is 120/30 days), because then it's tricking the computer to get the claim to go through, and the dr's order doesn't justify the increased usage.)

With this situation, has the patient actually been using it q4h? I highly doubt they are waking up through the night or whipping out their nebulizer at work or school, in order to use q 4 hour. Most likely the dr wrote it that way, but actually told the pt to use q 4 h prn, or told the pt to use QID but they could have an extra dose during bad spells. Or maybe the dr told the pt QID, and had 4 in his mind and wrote q 4h when he really meant q 6h. It wouldn't be surprising if the patient never actually looked at the label on their box, and has just been taking the medication however they felt like taking it.

TLDR, don't sweat over this situation. And if you are still concerned even though there is no reason to be, talk to the patient about their actual usage first, before calling the doctor.
 
Good point. I have gotten rxs for qty of 2 inhalers though, usually for kids maybe one for school one for home and it does go through with a days supply that u input for one inhaler (i.e. if per sig one inhaler lasts 25 days we bill 25 days for both inhalers)


grumpyRph said:
Lol! This post cracked me up on my lunch today! Way to overthink things!

I’ve always been taught and under the impression that insurance audit will only care about day supply if you’re giving a higher amount than what is normal for a day supply. Like an extreme case would be three advair inhalers billed for 30 days. Like duh.

But if you extend the day supply like in this example and the patient runs out early that’s more of a inconvience for the patient rather an audit issue for insurance. I was taught they wouldn’t really look at specific directions. Just quantity versus day supply. Like an example of this is ompreazole 40mg bid but u bill 90 for 90 days. At least the patient gets some but then you worry about the pa for next fill...sorta thing. 🙂
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Curiousone1111 said:
Good point. I have gotten rxs for qty of 2 inhalers though, usually for kids maybe one for school one for home and it does go through with a days supply that u input for one inhaler (i.e. if per sig one inhaler lasts 25 days we bill 25 days for both inhalers)
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This would be fraud, because 2 inhalers would last 50 days per the directions. Just because it "goes through", doesn't mean you won't get a charge-back if/when you are audited.
 
BidingMyTime said:
This would be fraud, because 2 inhalers would last 50 days per the directions. Just because it "goes through", doesn't mean you won't get a charge-back if/when you are audited.
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We typically call to make sure we have proper documentation but 9 times out of 10, the insurance rep tells us to bill for the max days allowed (25 in this case) and document the conversation.
 
WorthlessOxygen said:
We typically call to make sure we have proper documentation but 9 times out of 10, the insurance rep tells us to bill for the max days allowed (25 in this case) and document the conversation.
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I don't think you're understanding them correctly.

Dispensing 1 inhaler with instructions "1 puff q12h" as 25 or 30 days supply is fine because you can't possibly dispense only 60 puffs.

In the case of 2 inhalers, you absolutely can dispense only 1.
 
CetiAlphaFive said:
I don't think you're understanding them correctly.

Dispensing 1 inhaler with instructions "1 puff q12h" as 25 or 30 days supply is fine because you can't possibly dispense only 60 puffs.

In the case of 2 inhalers, you absolutely can dispense only 1.
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I am fairly easily confused so you may be absolutely right but I think Curiousone1111 and I are talking about the same thing: a prescription to dispense 2 inhalers so that they can take 1 to school and leave the other one at home, say with directions to use 2 inhalations every 6 hours PRN. The actual days supply should be 50 but if the insurance doesn't cover >30 we are typically told to submit as 30 for that fill https://forums.studentdoctor.net/members/curiousone1111.949085/
 
I guess I would wait for 50 days then and dispense two since the kid needs both? the reason I thought it was okay was since one is for home use and the other for school, but ur right since they wouldnt be using both at the same time lol good point!

BidingMyTime said:
This would be fraud, because 2 inhalers would last 50 days per the directions. Just because it "goes through", doesn't mean you won't get a charge-back if/when you are audited.
Click to expand...
 
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