Avoiding Humana Audits for Deceased Patients

Humana has recently sent out another round of audits to pharmacies with the subject line: Review of claim(s) billed after member’s deceased date. The review is taking place, sometimes more than a year after the date of service, because Humana identified some Medicare Part D claims paid after the member passed away. Why would Humana wait so long to review these claims, and why did they not stop them at point of sale? Unfortunately, there is usually significant lag time from when a patient passes away to when this information is reported to the Social Security Administration, and then to CMS and plan sponsors.

Pharmacies have 30 days from the date on the audit letter to provide evidence demonstrating the appropriate billing of these claims. Please see the Humana guidelines set below to combat these recoupments.

Claim date would need to be within 14 days from deceased date for claims billed to patients not in a long-term care facility (retail) and 32 days from deceased date for patients who reside in a long-term care facility.

Accepted documentation for a deceased member (not all-inclusive):

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  • Signature log (of personal representative)
  • Delivery log/mail order shipping receipt
  • Manifest
  • Obituary with different deceased date
  • E-kit Rx

Accepted documentation for a member who is NOT deceased:

  • Signed signature log
  • Signed delivery log
  • Obituary with different deceased date
  • Prescriber statement
  • Member statement

PAAS Tips:

  • Always obtain member consent prior to delivery of any auto-refilled medications
    • This is a Medicare requirement to prevent waste
  • If dispensing a medication to a physician’s office for administration (e.g., Invega®), the pharmacy should have a log or reconciliation process to ensure the patient receives the medication in a timely fashion
  • Leaving a medication at a patient’s door without obtaining a signature can result in the claim being flagged for recoupment (if audited). To mitigate this risk, include a PAAS National® Trifold Mailer form with the delivery which the patient can return to the pharmacy to ensure adequate proof of dispensing is on file
  • Use extra caution with controlled substances, especially if being requested by a different family member or if only controlled substances are being refilled
  • Please see the following Newsline articles for more information on compliant delivery/signature logs:

Jennifer Ottman, CPhT