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

[justjoe]

Let's say that you have a script for hydrocodone/apap 10/325, take 1 to 2 tabs po q 4-6h prnp #60

You enter the day supply as "5." If the insurance rejects and says, DUR reject, HD (high dose) max of 3 per day, can you just change the day supply to "20," and tell the patient that it has to last 20 days, or do you have to enter an accurate day supply and do the DUR codes (and possible a prior authorization)?

Thanks.

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[Rouelle]

Doing this on a controlled substance can be particularly problematic. There are PMP issues, refill too soon issues if another script issued, and soft-core insurance fraud issues.

 

[owlegrad]

It's insurance fraud plain and simple. Do not do it. If they are ok with making it last 20 days have them go back to the prescriber to get a script with directions that make it last 20 days. Otherwise they can pay cash or pray to the pharmacy gods that a PA will be done.

 

[Deja]

It's insurance fraud plain and simple. Do not do it. If they are ok with making it last 20 days have them go back to the prescriber to get a script with directions that make it last 20 days. Otherwise they can pay cash or pray to the pharmacy gods that a PA will be done.

this is insurance fraud? it's done all the time in retail on all kinds of meds lol I don't do it for controls cz threre are refill too soon issues and such... but yeah

 

[Sine Cura]

Retail pharmacists commit fraud all the time by allowing inaccurate claims to be submitted. Allowing Rx for topicals to be billed without getting a gram quantity to apply per administration. Or allowing Rx for inhalers to be billed without a specific quantity specified on the Rx. Or letting a 10 mL vial of testosterone to be billed for 90 days when the dose is 0.3 ml per week. Or allowing invalid controls to be billed to insurance (incomplete oral prescription, fake Rx or invalid prescription forms). Etc etc

 

[Ackj]

If you do this, you are the worst. Sure it gets the problem out of your hair, but you're just kicking the can down the road for whoever has to do the refill. And then it's worse, because "it was fine beforeee, the other pharmacist filled itttt" as insurance says it can't be filled for another 20+ days.

 

[owlegrad]

this is insurance fraud? it's done all the time in retail on all kinds of meds lol I don't do it for controls cz threre are refill too soon issues and such... but yeah

Some things are unavoidable, like a cream that would last 35 days but insurance will only pay for 30 days. 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! And the fact that it is for a control doesn't make it any better...

 

[owlegrad]

Retail pharmacists commit fraud all the time by allowing inaccurate claims to be submitted. Allowing Rx for topicals to be billed without getting a gram quantity to apply per administration. Or allowing Rx for inhalers to be billed without a specific quantity specified on the Rx. Or letting a 10 mL vial of testosterone to be billed for 90 days when the dose is 0.3 ml per week. Or allowing invalid controls to be billed to insurance (incomplete oral prescription, fake Rx or invalid prescription forms). Etc etc

Well if a pharmacy is deliberately filling fake controls it has a bigger problem than insurance fraud.

 

[Sine Cura]

How "unavoidable" people see things is basically up to the individual's tolerance for risk or ignorance of risk. Days supply on a control is an easy call not to fudge day supply because of all the attendant problems that come with controlled substances. Topicals I suspect most do not care unless it is actually expensive. Eye drops it is common for plans to reject unless the minimum day supply is put in or even your own company imposes a minimum day supply unless you call the help desk for an override. For vitamin drops even some PBMs let you override 50 for 30 with a call. Testosterone, make people get 1 mL vials or go somewhere else.

And filling controls written on invalid prescription forms occurs all the time in California because the DOJ doesn't care to enforce it (notorious offenders include UCSF, Molina, Dignity Health, Western Dental, Kaiser etc... security printers like SP 01, whatever company that is), and the Boards of Medicine, Dentistry et al don't care, but the Board of Pharmacy might ding you with an unprofessional conduct citation and you can't weasel your way out of it because "everyone else does it." I guarantee you 99.9% of all practicing pharmacists in CA in retail or outpatient like Kaiser have filled invalid controls in 2017 and the 0.01% are considered anal sticklers for the law.

 

[Deja]

Some things are unavoidable, like a cream that would last 35 days but insurance will only pay for 30 days. 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! And the fact that it is for a control doesn't make it any better...

I'm still not sure this is fraud... especially when you add in the as needed part...

 

[owlegrad]

I'm still not sure this is fraud... especially when you add in the as needed part...

Ok explain to me how lying to the insurance company in order to get a paid claim is not the exact definition of insurance fraud.

The PRN part is irrelevant. The days supply is still decided by math not insurance coverage.

 

[txpharmguy]

Let's say that you have a script for hydrocodone/apap 10/325, take 1 to 2 tabs po q 4-6h prnp #60

You enter the day supply as "5." If the insurance rejects and says, DUR reject, HD (high dose) max of 3 per day, can you just change the day supply to "20," and tell the patient that it has to last 20 days, or do you have to enter an accurate day supply and do the DUR codes (and possible a prior authorization)?

Thanks.

Enter correct days of supply. Override DUR: HD, R0, 1B

 

[Deja]

Ok explain to me how lying to the insurance company in order to get a paid claim is not the exact definition of insurance fraud.

The PRN part is irrelevant. The days supply is still decided by math not insurance coverage.

well logically 1 qid prn is at most 4 times a day but as needed means the patient can take less... so it's not really lying... also had the insurance company themselves call to just change the day supply so theres that... who knows maybe you are right, but like I said, it happens a lot... happens a lot in inhalers too.. so technically you should either call the doctor to change the direction or PA for everything and we know that doesn't happen (doctors usually write a standard sig for prn meds but actually tells patients to take less)

 

[Baalzeebub]

Why would you go from a 5 days supply to 20? If its max 3g/day tylenol then change to 7 days and it should go through, yet still close enough that its not commiting fraud.

 

[owlegrad]

well logically 1 qid prn is at most 4 times a day but as needed means the patient can take less... so it's not really lying... also had the insurance company themselves call to just change the day supply so theres that... who knows maybe you are right, but like I said, it happens a lot... happens a lot in inhalers too.. so technically you should either call the doctor to change the direction or PA for everything and we know that doesn't happen (doctors usually write a standard sig for prn meds but actually tells patients to take less)

Days supply isn't decided by how infrequently a medication can be taken though. It's decided by how frequently it can be taken. You have to know this. Just because "it happens all the time" doesn't make it right. And I reject the statement that it happens all the time...maybe it happens all the time in your pharmacy because you allow it to, but I never knowingly allowed it to have for tablets of a controlled substance.

Inhalers, tubes, etc, sure, all day every day.

 

[Digsbe]

I don't for a few reasons...

Likely your software reports the day supply to the PDMP, putting it in wrong reports it incorrectly.

From a clinical standpoint, if the insurance has a flag on the dosing there is *usually* a good reason for it. If the MD wants the patient on that dose they can fill out the PA request.

I'd rather not take risks with controls or be responsible for a stupid charge back. If it requires a PA or rejects it's going to have a PA go through or they can cash it out after I consult with the prescriber if I also think it's a high dose.

 

[Lnsean]

this is insurance fraud? it's done all the time in retail on all kinds of meds lol I don't do it for controls cz threre are refill too soon issues and such... but yeah

umm yea...you're fudging and submitting false information to get a paid claim. will anything happen to you? probably not...there's a very small chance that a patient overdoses and dies and the family sues and it's found that you fudged the day supply to get the claim to go through when it was obvious the insurance said no.

 

[wucool33]

Wait wait wait... are you guys saying I'm committing fraud for putting in the wrong day supply for stuff like sumatriptan and zofran, where the insurance only pays for #9 per 21 days? This is news to me... craziness

 

[Deja]

Days supply isn't decided by how infrequently a medication can be taken though. It's decided by how frequently it can be taken. You have to know this. Just because "it happens all the time" doesn't make it right. And I reject the statement that it happens all the time...maybe it happens all the time in your pharmacy because you allow it to, but I never knowingly allowed it to have for tablets of a controlled substance.

Inhalers, tubes, etc, sure, all day every day.

Well my first comment said I never do it for controlled meds and I have worked in multiple pharmacies... my main point was you made a big deal about this been fraud and I'm saying it happens a lot with other meds, if you are going to make a point about this being fraud then you shouldn't do this period, controls or not... also with someone saying patient dying of overdose... ofc you wouldn't dispense something if the direction is over the safe limit (duh!), but that wasn't the main point

 

[Deja]

Wait wait wait... are you guys saying I'm committing fraud for putting in the wrong day supply for stuff like sumatriptan and zofran, where the insurance only pays for #9 per 21 days? This is news to me... craziness

see this is what I'm talking about... you guys are saying the prn part doesn't matter and you are committing fraud.. tell me your pharmacy calls the doctor for every little things like this (owl, idk maybe the retail pharmacy that you work at really does call on every little thing, but if you think that's how majority of retail operates then idk what to say)... I rest my case

 

[owlegrad]

Well my first comment said I never do it for controlled meds and I have worked in multiple pharmacies... my main point was you made a big deal about this been fraud and I'm saying it happens a lot with other meds, if you are going to make a point about this being fraud then you shouldn't do this period, controls or not... also with someone saying patient dying of overdose... ofc you wouldn't dispense something if the direction is over the safe limit (duh!), but that wasn't the main point

Well, we agree about that at least. I don't see how this is even controversial. You shouldn't commit insurance fraud. Seems very black and white to me.

Just in case you are interested, I rarely called about Zofran because those scripts usually came from the ER. If the patient wanted to pay cash they could, or they could go back and request a script for directions that matched what the insurance was willing to cover. You realize every time you misrepresent the days supply the insurance company can take back the claim? I assume you enjoy filling prescriptions for free?

For sumatriptan I usually started the PA process. The prescribers in my area didn't seem to mind doing PA's for triptans, I presume they are used to it.

umm yea...you're fudging and submitting false information to get a paid claim.

It seems obvious, right?

 

[Lnsean]

Wait wait wait... are you guys saying I'm committing fraud for putting in the wrong day supply for stuff like sumatriptan and zofran, where the insurance only pays for #9 per 21 days? This is news to me... craziness

That's not a high dose limit...that's just a hard limit of x number of pills per month. Most rejections will clearly say this and the insurance is telling you to do it and inform the patient. OP asked if he's able to change a high-dose limit and fudging the day supply to make it seem like it's not high dose. The former can be defended in court...the latter no.

 

[wucool33]

That's not a high dose limit...that's just a hard limit of x number of pills per month. Most rejections will clearly say this and the insurance is telling you to do it and inform the patient. OP asked if he's able to change a high-dose limit and fudging the day supply to make it seem like it's not high dose. The former can be defended in court...the latter no.

Owle seems to be disagreeing with you... he would make patient pay cash or do a PA...

 

[Deja]

also happens a lot on eye drops... like lantanoprost... idk I think owl has only worked in one retail pharmacy so far and that's how he was taught... I can't imagine making ppl pay cash or call the doc to do the PA every single time... and like I said I've had insurance calling me to just change the day supply before... and never have I gotten an audit from insurance from things like this... but if you are the type of pharmacist that likes to call on everything while getting **** done and not annoying everyone else, more power to you

 

[Lnsean]

Owle seems to be disagreeing with you... he would make patient pay cash or do a PA...

and that's fine...I wouldn't fudge day supply on things that can come back to me. He is technically right...but I just don't follow it with everything I do.

 

[CetiAlphaFive]

[QUOTE="Sine Cura, post: 19116260, member: [/QUOTE]Allowing Rx for topicals to be billed without getting a gram quantity to apply per administration. [/QUOTE]

It depends on the third party.

Some instruct pharmacists to assume that X in "apply X times daily" is 1 gram.

 

[Sparda29]

Retail pharmacists commit fraud all the time by allowing inaccurate claims to be submitted. Allowing Rx for topicals to be billed without getting a gram quantity to apply per administration. Or allowing Rx for inhalers to be billed without a specific quantity specified on the Rx. Or letting a 10 mL vial of testosterone to be billed for 90 days when the dose is 0.3 ml per week. Or allowing invalid controls to be billed to insurance (incomplete oral prescription, fake Rx or invalid prescription forms). Etc etc

What's with this **** recently? Why can't we just go back to giving out the largest tube, smallest day supply possible so they can refill often and apply as directed?

My favorite was Diclofenac 3% gel #300 grams ap bid ud 30 day supply. Now you gotta do **** like ap 5 grams to affected pain areas (back, knees, elbows, neck) bid

 

[zelman]

I don't think this is a 100% cut and dry issue. When insurance companies were going nuts about "max #15 zolpidem per 30 days" for my patients who wanted to pay cash for 15 more, I would just bill 15 through insurance and 15 cash but put a 30 day supply on both. That way "too soon" warnings would pop up on early fills.

 

[Dr Wario]

Wow this thread is whack...I have never ever heard of an insurance company doing a chargeback because inputted day supply was too HIGH, do you know why? Because no one f-ing cares except the patient when they need to pay cash to get more pills. People wasting time on stuff like this is why the real problems in pharmacy still continue. Spend your time cracking down on pill mills and pharmacy hoppers, not on insurance frauds that don't exist.