use as directed

[Muse600]

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what else can you put on the sig if the MD wrote use as directed?

insurance audits don't want that there, so I've been using "Use as directed per packaging" or "use as directed per physician's instructions"...but I'm not sure if that really makes it okay

 

[BMBiology]

how about, "use as directed per your insurance company"?

 

[farmadiazepine]

Well it depends on what the medicine is. If its meclizine 25 mg #30 tabs use as directed, who cares? The ins company will never audit that.

If its Novolog 9 vials = 3 months supply uud, then you just better write on the hardcopy rx, patient is using a maximum amount of "x" units per month per md instruction, to cover your ass

Same applies to all high cost meds.. like tripans, neupogens, neulastas, all those related drugs, etcs, etc.

you can write "use as directed" on your label and submit that claim to the insurance. the only thing you want to do is note on the hardcopy to cover your ass.

 

[Pharmpills]

what else can you put on the sig if the MD wrote use as directed?

insurance audits don't want that there, so I've been using "Use as directed per packaging" or "use as directed per physician's instructions"...but I'm not sure if that really makes it okay

Use as directed per packaging can have many faults, with the most obvious being the package doesn't have directions . Unless you are talking about z-pack, medrol dose pack, etc.
Use as directed is not used as much anymore and even if you happen to use it the appeals process for the insurance allows you to contact the MD for more specific directions. The problem with that though is alot of times the quantity when calculated is far below what the doctor wrote in the first place and they will pay you only for what the patient was supposed to get and not what was dispensed.

 

[Old Timer]

Use as directed per packaging can have many faults, with the most obvious being the package doesn't have directions . Unless you are talking about z-pack, medrol dose pack, etc.
Use as directed is not used as much anymore and even if you happen to use it the appeals process for the insurance allows you to contact the MD for more specific directions. The problem with that though is alot of times the quantity when calculated is far below what the doctor wrote in the first place and they will pay you only for what the patient was supposed to get and not what was dispensed.

You are only partly correct. The only time you get in trouble with as directed is if the directions can be variable (insulin test strips, etc) or where the amount dispensed is outside of the normal clinical dosing (30 Imitrex 100mg for a 30 day supply). Your job as a pharmacist is not to get a paid claim it is to get paid claim that can withstand scrutiny. If you document what you did and why you did it, you will be fine. There are Neo-Nazi states like Delaware which prohibit as directed dosing.

 

[schamj01]

I hate use as directed because there've been many times where the patient didn't know how the doctor wanted them to take the rx. I hate guessing...doesn't make them very happy either.

 

[Albo]

My pharmacy law professor who holds a PharmD/JD told us to never put USE AS DIRECTED because all the liability is on the Pharmacist. He said he had been on cases where the pharmacist has lost for putting USE AS DIRECTED. Neither less i see this happening at my pharmacy all the time and no one seems to care.

 

[All4MyDaughter]

I hate use as directed because there've been many times where the patient didn't know how the doctor wanted them to take the rx. I hate guessing...doesn't make them very happy either.

We call and clarify. I work at an independent, and if I verify something that isn't going to withstand scrutiny, I'm going to hear about it from the owner. And sometimes clarifying what the doctor wants isn't enough. Like for test strips on Medicare. They only pay for a certain amount for non-insulin patients, no matter what the doctor wants. So you have to keep that in mind too.

 

[BenJammin]

If you put "use as directed" as a sig on a bottle, you deserve all the hell that is coming your way. What on earth are they teaching you guys in school?

 

[Praziquantel86]

If you put "use as directed" as a sig on a bottle, you deserve all the hell that is coming your way. What on earth are they teaching you guys in school?

A little harsh. Almost all the transplant patients we send out of the hospital end up getting "Use as directed" on their prescriptions for tac/CsA. Putting a blanket "Take 2 caps by mouth twice daily" would be dangerous because, in all likelihood, that dose is going to change by their next clinic visit. Similar story with insulin that is being titrated.

Unless you're advocating for a new prescription and trip to the pharmacy every time an insulin dose changes, or a transplant patient heads to clinic, there isn't a very good option. One size does not fit all.

 

[BenJammin]

A little harsh. Almost all the transplant patients we send out of the hospital end up getting "Use as directed" on their prescriptions for tac/CsA. Putting a blanket "Take 2 caps by mouth twice daily" would be dangerous because, in all likelihood, that dose is going to change by their next clinic visit. Similar story with insulin that is being titrated.

Unless you're advocating for a new prescription and trip to the pharmacy every time an insulin dose changes, or a transplant patient heads to clinic, there isn't a very good option. One size does not fit all.

I disagree and that is not what I am advocating. Insurance companies are going to eat you alive and with the direction it has been heading, they are only going to get pickier. Just wait until you dispense an expensive cancer drug with "use as directed" and the insurance audits you only to refuse to pay because of how vague the directions are. It has happened before!

 

[All4MyDaughter]

A little harsh. Almost all the transplant patients we send out of the hospital end up getting "Use as directed" on their prescriptions for tac/CsA. Putting a blanket "Take 2 caps by mouth twice daily" would be dangerous because, in all likelihood, that dose is going to change by their next clinic visit. Similar story with insulin that is being titrated.

Unless you're advocating for a new prescription and trip to the pharmacy every time an insulin dose changes, or a transplant patient heads to clinic, there isn't a very good option. One size does not fit all.

The problem is insurance chargebacks and audits. "Use as directed" is not acceptable because it doesn't allow the dispensing pharmacy to calculate a days supply. I would call every time for directions on those transplant drugs because I am not going to be responsible for our pharmacy losing money when we get audited.

The other problem with escalating doses without issue new scripts is that patients start to run short. This is especially problematic on insulin, when patients are self titrating. If they start with 10 units of Lantus QHS they are going to get one vial per month and they have extra. Once they are titrated to 50 units/day, that vial will only last them 20 days, but insurance won't pay because it's too soon. I recently had a patient who was going without insulin for two weeks because the directions on her vial were incorrect.

So yes, the proper thing to do when a dose changes is to issue a new RX. That helps the patient avoid insurance issues and helps the pharmacy avoid losing money.

Another option (and this applies more to insulin than transplant meds, of course) is to write the RX with some ceiling dose in mind, if you are titrating or if usage is variable. For instance, I'm currently using an insulin pump and have rather erratic insulin requirements. My script is written for Apidra - use up to 60 units in pump daily - dispense QS. I have to get a vial every 16 days because the insurance company won't pay for more than 30 DS. It's working ok now, but when I start to consistently use more than 60 units/day I will need a new RX.

I disagree and that is not what I am advocating. Insurance companies are going to eat you alive and with the direction it has been heading, they are only going to get pickier. Just wait until you dispense an expensive cancer drug with "use as directed" and the insurance audits you only to refuse to pay because of how vague the directions are. It has happened before!

Why the attitude? This post is better than your last one in this thread, but there's no need to address anyone (especially more experienced practitioners) disrespectfully.

 

[3boooda]

how about, "use as directed per your insurance company"?

That's a good one.

 

[BenJammin]

Why the attitude? This post is better than your last one in this thread, but there's no need to address anyone (especially more experienced practitioners) disrespectfully.

What are you talking about? Nowhere in that post did I use disrespectful language. If addressing a real issue pharmacists are experiencing or will experience is disrespectful then we, as a profession, need to grow a thicker skin. At some point, this nit picky language about using extra vials and issuing new scripts is going to be trivial to a retail chain or independent owner. Pick your poison: a one dollar vial or a one thousand dollar audit.

I think it's a crazy idea to expect new scripts for patients that are getting adjustments to their insulin but money talks. When insurance companies start refusing payment because we think that's a crazy idea, we'll change our tune really fast. Imagine a $10,000 bill from an insurance company because you put "use as directed" as a sig for a patient who is changing their dose repeatedly. THAT is the kind of hell that I am referring to.

 

[All4MyDaughter]

What are you talking about? Nowhere in that post did I use disrespectful language. If addressing a real issue pharmacists are experiencing or will experience is disrespectful then we, as a profession, need to grow a thicker skin. At some point, this nit picky language about using extra vials and issuing new scripts is going to be trivial to a retail chain or independent owner. Pick your poison: a one dollar vial or a one thousand dollar audit.

I think it's a crazy idea to expect new scripts for patients that are getting adjustments to their insulin but money talks. When insurance companies start refusing payment because we think that's a crazy idea, we'll change our tune really fast. Imagine a $10,000 bill from an insurance company because you put "use as directed" as a sig for a patient who is changing their dose repeatedly. THAT is the kind of hell that I am referring to.

I'm talking about this remark:

If you put "use as directed" as a sig on a bottle, you deserve all the hell that is coming your way. What on earth are they teaching you guys in school?

I agree with Prazi that it's a little harsh. I would also add disrespectful. You have not worked even one day as a pharmacist, so settle down.

 

[BenJammin]

I'm talking about this remark:



I agree with Prazi that it's a little harsh. I would also add disrespectful. You have not worked even one day as a pharmacist, so settle down.

You know nothing about my work experience so why you made that comment, which was more disrespectful than anything I've said, is beyond me. One does not need pharmacist experience to understand the business side of insurance. Even a technician can confirm the splashes insurance companies have made in being even more picky than a gridlock like Medicare part D.

From the experience that I do have, contrary to your baseless statement, I do know that covering your rear end is something we all need to be doing. That includes documenting everything and I mean everything. Clear and concise. "use as directed" is not clear and concise.

I'm the told you so guy. When i die, my gravestone will say "i told you i was sick". When and if an insurance company audits you or me or anybody for something like that, it's gonna come out of your paycheck or your bottom line depending on your perspective. But I guess if your income is high then an insurance penalty isn't a big deal. It is to me and it should be to everyone here.

"Hell" isn't a disrespectful word, it's a reality that some retail settings are experiencing in more ways than one. Time to buckle down and get to the real issues! If only more people were willing to be proactive.

 

[Praziquantel86]

I disagree and that is not what I am advocating. Insurance companies are going to eat you alive and with the direction it has been heading, they are only going to get pickier. Just wait until you dispense an expensive cancer drug with "use as directed" and the insurance audits you only to refuse to pay because of how vague the directions are. It has happened before!

I've been audited in a retail setting before, and yes, it sucks. That's why you document your reasoning behind your dispense amount (as suggested by A4MD). I'm not going to make a person come to the pharmacy every 3 days to pick up another few pills and pay another copay. If the auditors don't like my reasoning and carefully documented prescriptions, then I'll fight them over it - but I'll keep the patient from becoming involved in bureaucratic nonsense that shouldn't and doesn't concern them.

 

[All4MyDaughter]

You know nothing about my work experience so why you made that comment, which was more disrespectful than anything I've said, is beyond me. One does not need pharmacist experience to understand the business side of insurance. Even a technician can confirm the splashes insurance companies have made in being even more picky than a gridlock like Medicare part D.

From the experience that I do have, contrary to your baseless statement...

My statement was not baseless. It is accurate. You have never worked a day as a pharmacist. That's all I said, and it's true. So, settle down.

 

[BenJammin]

My statement was not baseless. It is accurate. You have never worked a day as a pharmacist. That's all I said, and it's true. So, settle down.

Prove it.

 

[owlegrad]

Prove it.

You self-identify as a student, and post stuff like this:

I have no idea why GPA is even a factor. I have a 3.0 and I work 10x as hard as some of these people in my class who have 4.0s. If you are socially deficient and don't seem like you can handle the job then your grades don't impress anyone.

Proof is somewhat hard without trying to figure out who you are IRL and calling your school to determine your educational status, but I think it is pretty clear you are a student. 😀

EDIT: Never question A4MD!

 

[ImmunoPharmD]

Prove it.

I think prescriptions like previdents/suprep/medrol dosepak we can write us ad/ud. So no, we would not chastise ourselves or patients for doing that.

Also, I'd like to add that the only time it is appropriate to use that sig is when 1.) the prescription contains no sig, and 2.) that prescription must have instructions per use. You can't have one without the other. So I'm not really sure why it is such a mess to the insurance company if we use that sig...unless we are getting lazy and say meh.. 30 tabs for 30 days = as directed. lol

 

[BenJammin]

You self-identify as a student, and post stuff like this:



Proof is somewhat hard without trying to figure out who you are IRL and calling your school to determine your educational status, but I think it is pretty clear you are a student. 😀

EDIT: Never question A4MD!

Oh boohoo, my personal information is none of your business. Just because I wrapped up pharmacy school and got hired at a hospital does not mean I'm required to tell you all about it. I don't self identify as a student anymore. But I'm a lot smarter than most of you in that I don't give out personal information that can identify me to others. Trust me when I tell you that no one on this forum is anonymous.

Blowing off an issue that could cost a company thousands could get you blacklisted. Just saying. People much bigger than you and I are reading this forum.

 

[BenJammin]

I think prescriptions like previdents/suprep/medrol dosepak we can write us ad/ud. So no, we would not chastise ourselves or patients for doing that.

Also, I'd like to add that the only time it is appropriate to use that sig is when 1.) the prescription contains no sig, and 2.) that prescription must have instructions per use. You can't have one without the other. So I'm not really sure why it is such a mess to the insurance company if we use that sig...unless we are getting lazy and say meh.. 30 tabs for 30 days = as directed. lol

Peridex and medrol dosepaks are definitely exceptions to the rule because the directions never deviate from the ones on the bottle/box. Insulin, chemo, HIV, and long term care drugs are another story. You are asking for trouble when you give vague directions to a nursing home facility.

 

[Ackj]

Also, I'd like to add that the only time it is appropriate to use that sig is when 1.) the prescription contains no sig, and 2.) that prescription must have instructions per use.

So... never? Pretty sure all prescriptions must have a sig and instructions for the patient.

 

[All4MyDaughter]

Oh boohoo, my personal information is none of your business. Just because I wrapped up pharmacy school and got hired at a hospital does not mean I'm required to tell you all about it. I don't self identify as a student anymore. But I'm a lot smarter than most of you in that I don't give out personal information that can identify me to others. Trust me when I tell you that no one on this forum is anonymous.

So confrontational. Classic internet tough guy. 🙄

But I think my point is proven. 😀

 

[ImmunoPharmD]

Oh boohoo, my personal information is none of your business. Just because I wrapped up pharmacy school and got hired at a hospital does not mean I'm required to tell you all about it. I don't self identify as a student anymore. But I'm a lot smarter than most of you in that I don't give out personal information that can identify me to others. Trust me when I tell you that no one on this forum is anonymous.

Blowing off an issue that could cost a company thousands could get you blacklisted. Just saying. People much bigger than you and I are reading this forum.

Uh oh....can you explain a little more?

 

[owlegrad]

So confrontational. Classic internet tough guy. 🙄

But I think my point is proven. 😀

I almost hate to break it to him that he is still self identifying as a student

 

[All4MyDaughter]

I almost hate to break it to him that he is still self identifying as a student

I know, right!?!?