When you are preparing for an audit, a PAAS National® analyst has likely told you to ensure a prescriber’s Drug Addiction Treatment Act (DATA) 2000 Waiver ID, or XDEA number, is included on prescriptions for medications used to treat opioid use disorder along with their regular DEA number. Effective December 29, 2022, the date the Consolidated Appropriations Act of 2023 (“The Act”) was signed, the need for prescribers to have XDEA numbers to prescribe such medications has been eliminated.
Subsequently, on January 12, 2023, the DEA released an informational document. In it, they state their support regarding the policy reform, stating, “At DEA, our goal is simple: we want medication for opioid use disorder to be readily and safely available to anyone in the country who needs it [and] the elimination of the X-Waiver will increase access to buprenorphine for those in need.” The document goes on to state “going forward, all prescriptions for buprenorphine only require a standard DEA registration number” but cautions that state laws and regulations still apply.
The Substance Abuse and Mental Health Services Administration (SAMHSA) echoes the DEA’s sentiment, stating “all practitioners who have a current DEA registration that includes Schedule III authority, may now prescribe buprenorphine for Opioid Use Disorder in their practice if permitted by applicable state law…”
Despite the X-Waiver no longer being mandatory, the Act did enact a new training requirement. In Chapter 6 of the Act is Section 1263 entitled “Requiring Prescribers of Controlled Substances to Complete Training”. It discusses ways to meet training requirements, such as prescribers completing no less than 8 hours of training on the treatment and management of patients with Opioid Use Disorder in a variety of settings. Currently, DEA and SAMHSA are working together to implement the new training requirement and state that this requirement will not go into effect until June 2023.
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- PBMs and third-party payors are often mute on these topics, leaving pharmacies guessing on appropriate actions (and corresponding audit risk)
- Comply with state and federal requirements for controlled substances
- For prescriptions written prior to 12/29/2022, ensure the XDEA number is present on the prescription
- If the pharmacy is filling/refilling a prescription written prior to 12/29/2022 and the provider did not have an XDEA number at the time, the prescription would likely be considered invalid by PBMs (and the DEA), and PAAS would suggest [conservatively] to get a new order from the provider
PBM Prescription Validation Requests Rose Nearly 20% in 2022!
Prescription Validation Requests (also known as claim reviews) are becoming a more frequent occurrence with many PBMs. In 2022, PAAS saw an 18% increase year over year. Some of the reasons these claims get flagged include:
While these requests are a nuisance, they can work to the pharmacy’s benefit. With the PBM looking at the claim prospectively (before payment is received), pharmacies can avoid incorrectly refilling medication if an error is detected. Conversely, if a pharmacy is not prompted to correct an error (when one exists) and the claim is refilled over the course of a year, the financial recoupments can be much greater upon audit. The frustration comes in when these claim reviews are repetitious, and false positives (i.e., no billing errors) – creating work for the pharmacy without the need for claim correction.
Below is a chart of the various PBMs conducting these prospective reviews and the details/nuances associated with each. OptumRx/EXL® makes up the majority of these pre-claim reviews that members report to PAAS. OptumRx defines the Prescription Validation Request (PVR) in their pharmacy manual as follows:
Administrator conducts limited scope prescription validation reviews for quality assurance purposes (“PVRs”), which are distinct from and are not considered audits. PVRs are utilized to verify the accuracy and validity of prescription claim submissions. Claims are monitored daily for appropriateness and potential billing errors and selected for review prior to payment. Network Pharmacy Providers are typically contacted via fax or email and asked to provide photocopies of specific documents and records related to its claims submitted to Administrator.Join today!
PBM
Title of Request
Days to Respond
Targeted Claims
Caremark®
Concurrent Claim Review
3
Compounds, non-FDA approved products, injections
Express Scripts®
Claims for Investigative Review
5
CII’s
Humana®
Pharmacy Claim Validation Request
3 business
Potentially misbilled claims
MagellanRx/Conduent
Claim Check verification review
7
High dollar (Emgality ®, insulin)
MedImpact
Pre-pay Claim Review
3 business
Potential billing errors
OptumRx/EXL®
Validation Request
14 business
High dollar (Humira®, Enbrel®, insulin, inhalers)
Prime Therapeutics
Initial Documentation Request
2
High-dose insulin
- Send the validation review request to PAAS National® right away as these can often have short deadlines
- Include a copy of the prescription and your backtag for the date of service in question so that we can verify claim billing
- Most requests do NOT require a signature log, but PAAS will confirm if required after reviewing your audit notice.
- Often, these claims are very recent and sometimes have not even left the pharmacy
- A response is required even if claim has been reversed
- If a claim is recent (within) 30 days, and there is a billing error, the pharmacy can often correct the claim (if applicable)
- If the PBM finds the claim to be accurately billed, the pharmacy will not receive any “results”
- Even though these requests are not typically labeled as an “audit”, PAAS has seen PBMs deny payment on the claim and/or issue “results”
- If the pharmacy received what looks like “results,” send to PAAS for guidance. The “results” may list an estimated overpayment amount which is often a consequence of external auditing entities not having real time claims access
(Unusual quantity and days’ supply combination)
(Unusual quantity and days’ supply, incorrect DAW code)
While PBMs have fancy names for these requests, make no mistake: if it looks like an audit, you must submit documentation like an audit, and you get results (and recoupments) like an audit, it is an audit!
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XDEA Numbers Have Been NiXed…but Not the Training
When you are preparing for an audit, a PAAS National® analyst has likely told you to ensure a prescriber’s Drug Addiction Treatment Act (DATA) 2000 Waiver ID, or XDEA number, is included on prescriptions for medications used to treat opioid use disorder along with their regular DEA number. Effective December 29, 2022, the date the Consolidated Appropriations Act of 2023 (“The Act”) was signed, the need for prescribers to have XDEA numbers to prescribe such medications has been eliminated.
Subsequently, on January 12, 2023, the DEA released an informational document. In it, they state their support regarding the policy reform, stating, “At DEA, our goal is simple: we want medication for opioid use disorder to be readily and safely available to anyone in the country who needs it [and] the elimination of the X-Waiver will increase access to buprenorphine for those in need.” The document goes on to state “going forward, all prescriptions for buprenorphine only require a standard DEA registration number” but cautions that state laws and regulations still apply.
The Substance Abuse and Mental Health Services Administration (SAMHSA) echoes the DEA’s sentiment, stating “all practitioners who have a current DEA registration that includes Schedule III authority, may now prescribe buprenorphine for Opioid Use Disorder in their practice if permitted by applicable state law…”
Despite the X-Waiver no longer being mandatory, the Act did enact a new training requirement. In Chapter 6 of the Act is Section 1263 entitled “Requiring Prescribers of Controlled Substances to Complete Training”. It discusses ways to meet training requirements, such as prescribers completing no less than 8 hours of training on the treatment and management of patients with Opioid Use Disorder in a variety of settings. Currently, DEA and SAMHSA are working together to implement the new training requirement and state that this requirement will not go into effect until June 2023.
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- PBMs and third-party payors are often mute on these topics, leaving pharmacies guessing on appropriate actions (and corresponding audit risk)
- Comply with state and federal requirements for controlled substances
- For prescriptions written prior to 12/29/2022, ensure the XDEA number is present on the prescription
- If the pharmacy is filling/refilling a prescription written prior to 12/29/2022 and the provider did not have an XDEA number at the time, the prescription would likely be considered invalid by PBMs (and the DEA), and PAAS would suggest [conservatively] to get a new order from the provider
Beware: Caremark is Monitoring High Quantity Utilization and Atypical Dispensing Habits
Beyond traditional desktop, on-site, investigational or invoice audits, Caremark performs various compliance reviews. These compliance reviews may include:
PAAS National® has recently reviewed a second round of these Rx Claim Review notices from members. While new for Caremark, PAAS has identified multiple versions of the letter primarily focusing on two areas of concern:
The brief, and poorly worded, letter states the pharmacy should evaluate the claims in question and consider whether the dispensing of these medications is appropriate. It concludes with “your cooperation is appreciated and will greatly assist us in our review”. Due to the ambiguous direction, pharmacies are unsure if they need to respond or provide any additional information or documentation to Caremark.
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Criminal HIPAA Charges Filed Against Compounding Pharmacy Sales Rep
Criminal HIPAA charges are not handed down frequently, but when an individual “knowingly” and inappropriately obtains and discloses a patient’s protected health information (PHI), they could face up to $50,000 in fines and up to one year in prison, according to 42 U.S.C. § 1320d-6. Additionally, if found guilty of obtaining or disclosing the information with the intent to sell, transfer, or use the PHI for commercial advantage, personal gain, or with malicious intent the penalties can increase up to $250,000 and 10 years in prison.
According to a October 20, 2022 Department of Justice press release, a former compounding pharmacy sales representative located in New Jersey is facing criminal HIPAA charges for obtaining unauthorized access to PHI with the intent to personally profit. The sales rep promoted compounded prescriptions and other medications which were subsequently filled by a Louisiana pharmacy. The sales rep and his co-conspirators knew which plans would reimburse significantly for certain compounded medications and the sales rep then recruited patients with that specific insurance. To do this, the sales rep gained access to a medical clinic where the doctor allowed him to have significant access to patient medical records. Since the sales representative was not an employee of the doctor’s office, he was not authorized to access the information without first obtaining proper release. The sales rep would then sift through medical records to identify patients with the sought-after insurance plan. The patient files would be tagged so the doctor could easily identify patients with the specific insurance plan so he knew whom he should prescribe the compounds. On occasion, the sales representative would even join the doctor and patient in the exam room as if he were employed by the medical office, which he was not.
Patients were targeted based on information illegally gained from within secure patient records, then they were prescribed and dispensed medically unnecessary compounded medications all as a result of this scheme.
Training staff to appropriately handle PHI, and discussing the consequences of mishandling PHI, is critical to preventing a breach and other unauthorized access to protected information—malicious or not. If you have not already taken advantage of the PAAS National® Fraud, Waste, and Abuse and HIPAA Compliance Program, now is a great time to reach out to a PAAS staff member to learn about the best program available to independent pharmacies. Ring in the New Year with confidence knowing that you have a method to provide your staff with comprehensive, community pharmacy focused HIPAA training.
Valid Prescriber/Patient Relationships and Marketing Concerns
With the U.S. Department of Health and Human Services Office of Inspector General’s (OIG) recent focus on telemedicine fraud, pharmacies may be wondering what their obligations are when determining a prescription’s authenticity – especially when it comes to whether a valid prescriber/patient relationship exists. Many PBMs, including Express Scripts, TRICARE, CVS Caremark, and OptumRx all have language in their provider manuals placing the responsibility on the pharmacy of ensuring a valid prescriber/patient relationship exists.
How can you determine if a prescriber/patient relationship is valid? Questions you may ask to verify this are:
Along with telemedicine, PBMs are also concerned about marketing practices of pharmacies. The provider manuals for Express Scripts, TRICARE, CVS Caremark, OptumRx, and Elixir all contain language surrounding what is not allowed and some, like Express Scripts, are known for using investigational audits to ensure compliance.
Prohibitions on certain marketing practices in these manuals include, but are not limited to:
Pharmacies must remain vigilant and always conduct marketing practices in a manner consistent with their state laws, federal laws, and Medicare regulations and guidelines.
PAAS Tips:
Top 10 PAAS National Articles of 2022
PAAS Audit Assistance members receive a monthly newsletter with new audit tactics and prevention tips. The printed newsletter, PAAS National® Newsline is only a fraction of the content that we put out each month as members have access to additional content online in the Member Portal, in addition to an archive of articles.
The top 10 Newsline articles for 2022 include:
Top eNewsline Exclusives: Articles that did NOT make print
PAAS Audit Assistance Admins can also keep their employees informed to increase engagement and lower audit results by adding employees to the Portal so that their whole staff has access to the eNewsline.
2023 Fraud, Waste & Abuse and HIPAA Compliance Program Updates
PAAS National® continuously monitors legislative and regulatory changes that may impact your Fraud, Waste & Abuse and HIPAA Compliance Program. We keep a close eye on enforcement from the Department of Justice, Office of Inspector General, State Attorney Generals, and Office for Civil Rights to help ensure the program meets interpretative standards. Furthermore, PAAS works to keep pace with Pharmacy Benefit Managers as they continue to add credentialing requirements that can be extremely difficult, and a significant nuisance, to independent pharmacies.
The PAAS National® FWA/HIPAA Compliance Program has implemented changes to ensure pharmacies continue to have a robust program in place. PAAS FWA/HIPAA compliance members can login to the member portal to view the 2023 FWAC and HIPAA Updates.
Administrators should review all Compliance tasks (located in the left-hand navigation on the PAAS Member Portal) at least annually to keep the program up-to-date and in compliance. Section 2.6 Updates of Policies and Procedures of your manual contains information on maintaining open lines of communication and the distribution of changes.
If you’re not a member of PAAS’ FWA/HIPAA compliance program, contact us today at (608) 873-1342 or info@paasnational.com to add the program for a discounted rate.
“We have been with PAAS for many years and added the FWAC/HIPAA material to our membership and as a compliance officer, I’ve never been more pleased with the program. If you have already made the best choice to have PAAS in your corner, then continue with the best for your FWAC/HIPAA needs.” – Member since 2010 from North Carolina
“PAAS National® Fraud, Waste, Abuse and Compliance educational sessions are unsurpassed. The PAAS National® Policy and Procedure manual that you create for your pharmacy is a must for all pharmacies to have for their staff. All of this keeps your pharmacy up to date with current pharmacy procedures and operations and ensure proper pharmacy practices going forward.” – Member since 2021 from New York
“A pharmacy without the compliance program does not have their bases covered and required work finished. I can sleep at night knowing this program keeps me protected and on task.” – Member since 2009 from Iowa
Natesto® Nasal Gel Pump – Bill It Right!
Pharmacies have begun to see more prescriptions for Natesto® (testosterone) nasal gel. Natesto® is indicated for primary hypogonadism and hypogonadotropic hypogonadism, whether those conditions were congenital or acquired. At this time, it is not approved for age-related hypogonadism or for male patient populations less than 18 years old.
Package Size
in Package
The recommended dose is 11 mg of testosterone (5.5 mg testosterone per nostril actuation) three times daily, preferably at the same time daily. Therefore, each package should be billed as a 10 days’ supply and a quantity of three packages would be dispensed for a 30 days’ supply, if prescribed as such. Despite needing to prime prior to initial use, no priming is necessary for the remainder of use and priming does not need to be factored in when computing the billed days’ supply.
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The Ballad of Snowbirds and Audits
The winter months have many pharmacies mailing prescriptions to their snowbird patients who leave their northern nests for more hospitable climates. Pharmacies want to keep these patients happy and coming back when the weather is nicer and may look to mailing maintenance medications to them when they have migrated out of state. Although these pharmacies may think they are doing the right thing for patient care, and their business, they may also be setting themselves up for audit failure.
Unfortunately, this does not just apply to northern states with snowbird patients. Many states now have laws that require nonresident pharmacies to obtain a license to ship, mail, deliver, or dispense prescription medications into their states. Auditors take advantage of these laws to recoup money from well-meaning pharmacies who may not even know that mailing a prescription out of state is a problem! For pharmacies situated close to the state border, delivering into a neighboring state carries the same risks. PAAS National® has seen these claims cited as law violations with limited appeal options.
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Start of New Year = Opioid Plan Rejects
PAAS National® analysts receive numerous calls at the start of the new year looking for guidance on opioid plan rejects. With the new year, many patients may be on a new Medicare Part D plan. Opioid prescriptions processed previously with no issues, may now reject at point-of-sale on the new plan.
With the opioid crisis on the rise, CMS acted in 2018 to closely monitor opioid use and safety of patients. Medicare Part D plans were required to implement opioid policies and work together with patients, prescribers, and pharmacies with this monitoring. These policies included real-time safety alerts at the pharmacy’s point-of-sale.
Here are the four Medicare Part D opioid safety alerts:
In August of 2022, CMS through the Medical Learning Network (MLN) published A Prescriber’s Guide to Medicare Prescription Drug (Part D) Opioid Policies. This guide offers guidance to both prescribers and pharmacies for patients using opioid medications. Pharmacies should note, alerts that cannot be resolved at point-of-sale may require providing patients with a copy of the CMS-10147 Medicare Prescription Drug Coverage and Your Rights form. This form provides instructions for patient to work with their prescriber and their Medicare plan to expedite coverage for their medication.
Pharmacies have an obligation to
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