FWA and HIPAA Compliance with Job Shadows and Interns

Students performing a job shadow or internship in the pharmacy need proper FWA/HIPAA training and preparation to be behind the pharmacy counter or you are inviting headaches into your operations (and potential legal complications).

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Ensure all students entering the professional area of the pharmacy have received proper HIPAA training. They will undoubtedly be exposed to Protected Health Information (PHI) and must know the proper policies and procedures to prevent a breach. Private information about friends, classmates, relatives, or other community members may be learned and this information could be tempting to share with others. By completing HIPAA training prior to exposure to PHI, the students will have a better understanding of the problem with disclosing PHI, including the civil monetary penalties and criminal consequences.

Pharmacy students completing their internship typically spend more time in the pharmacy than someone job shadowing. Interns assisting with daily operations such as billing, filling, counseling, and other professional services, must also complete FWA training. Though their time with your pharmacy may be temporary, these students have access to many of the same pharmacy operations as regular employees. The potential to oversee or partake in wasteful practices, diversion, or other fraudulent activities exists and FWA training must be completed. PAAS National® also recommends completing exclusion checks for interns against both the Office of Inspector General (OIG) and General Services Administration (GSA) lists.

PAAS FWA/HIPAA Compliance members can easily add students to your employee list in the PAAS Member Portal to give them access to the FWA/HIPAA online training modules and automatically receive daily OIG and GSA exclusion checks when the student’s profile is created.

PAAS Tips:

  • Before entering the professional service area of the pharmacy all students should complete HIPAA training
  • All interns should also receive FWA training
  • All interns should be checked against the OIG and GSA exclusion lists before entry into the pharmacy and at least monthly thereafter
  • Students performing a job shadow should have direct supervision
  • Check with your board of pharmacy for the required oversight of pharmacy student interns
  • PAAS FWA/HIPAA Compliance members should modify the student’s “termination date” when their rotation through your pharmacy ends to remove them from your list of active employees

Contact PAAS National® at (608) 873-1342 or info@paasnational.com for assistance regarding student access to the portal or to become an FWA/HIPAA Compliance member.

Pitfalls of Transferred Prescriptions

Transferred prescriptions are at high risk for audit recoupments. Every element required by state regulations is one additional pitfall that PBMs utilize to try and recoup on claims. These prescriptions are easily identified due to their origin code. The NCPDP Telecommunication Version D section 3.1.4 explains that an origin code of 5 is utilized for any pharmacy created prescription, which includes when pharmacists have authority to prescribe, when dispensing off a protocol and for prescriptions transferred in.

PAAS National® analysts frequently see audit results with recoupments for:

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  • Missing transfer elements – always double check your transferred prescriptions against your state’s transfer requirements to avoid these recoupments. Contact PAAS (608) 873-1342 or info@paasnational.com if you need assistance obtaining a copy.
  • Original written date – claims may be flagged as invalid when the written date is input incorrectly as the transfer date. Additionally, entering an incorrect written date could cause the pharmacy to accidently dispense the medication after the legal expiration date.
  • Central file – pharmacies that share a central file appear to be the newest pitfall with transferred scripts. Prescription data is maintained on one system for pharmacies under common ownership and the software allows for seamless sharing of information. This makes prescription transfers more efficient as the data is visible by all pharmacies on the shared system and a prescription can be pulled to a new location with a few keystrokes. Pharmacies have seen hefty recoupments during audits for missing transfer information by not providing sufficient data to show all transferred elements or common ownership and proof of a central file. PAAS has successfully assisted pharmacies facing recoupment for this issue and have already saved these members over $230,000.

PAAS Tips:

  • Review state transfer regulations
    • Ensure staff involved in taking, giving, and billing transferred prescriptions are familiar with the required elements of a valid transfer in your state
    • Create transfer Rx blanks with all required elements
  • Routinely perform a self-audit for prescriptions with an origin code of 5 and check hardcopies for accuracy

Updated Dispense in Original Container Chart

Medications that are required to be dispensed in their original container continue to appear in audits. Billing for a quantity that is not divisible by the full bottle size is a red flag to the PBM and, unfortunately, easily recoupable. Many of these products are sensitive to light/moisture or have only been studied under storage in their original container; thus, removing them from the original package may cause stability and potency issues. Product labeling can be obtained from the FDA’s DailyMed website, which was referenced by PAAS National® to update the Dispense in Original Container chart under the Tools & Aids section of the PAAS member portal.

For example, PAAS analysts have seen an increase in

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questions regarding Truvada® for HIV post-exposure prophylaxis (PEP). Prescribers are issuing scripts for 28 days to follow the PEP treatment guidelines by the CDC, but one of the drugs included in the CDC 28-day PEP treatment regimen is Truvada®, which comes in 30-count bottles with labeling to “dispense only in original container.” PAAS cannot recommend dispensing outside of FDA guidelines and advises the pharmacy to obtain authorization from the prescriber to dispense the full bottle.

Additionally, pharmacies dispensing to nursing homes or providing medication packaging to patients in the retail pharmacy setting must also follow the FDA guidelines to dispense in the original container.

PAAS Tips:

  • Print and display a copy of the PAAS National® Dispense in Original Container chart near the billing station
  • Place labels on the shelf by products required to be dispensed in their original container
  • Only bill these products for quantities divisible by the full bottle size to decrease audit risk
  • If necessary, contact the prescriber for authorization to change the prescribed quantity to facilitate dispensing in the original container and document the change with a clinical note
  • Contact PAAS with concerns or for further clarifications

Fraud, Waste, & Abuse and HIPAA Compliance Updates for 2021

PAAS National® continuously keeps close tabs on legislative and regulatory changes that may impact our members’ Fraud, Waste & Abuse and HIPAA Compliance Program. Monitoring enforcement from the Department of Justice and the Office for Civil Rights (OCR) also allows us to be aware of interpretative standards as well.

Furthermore, Pharmacy Benefit Managers (PBMs) are continuously adding and changing requirements to their credentialing process. Pharmacies need to be certain they are ready for these changes. The PAAS National® FWA/HIPAA Compliance Program has implemented changes to ensure pharmacies with our program will continue to have robust policies in place.

Does your pharmacy have a policy for Timely Submission of Claims? PAAS has increasingly become aware of this credentialing requirement. Having written policies in place will assist you with credentialing responses. PAAS FWA/HIPAA compliance members can now find this in Section 4.1.8 of their Policy and Procedure  Manual.

It is also important for pharmacies to be aware of OCR’s stepped-up enforcement for Pharmacies who are not providing timely access to patient records – fines for violations have exceeded $200,000. PAAS FWA/HIPAA compliance members should review Section 10.5.1.1 of their Policy and Procedure Manual and review our January 2020 Newsline article First Two Settlements for HIPAA Right of Access Initiative by OCR.

PAAS FWA/HIPAA compliance members can login to the member portal to view the full memo of 2021 FWAC and HIPAA Updates.

With our 24/7 web-based Portal, extensive customization, and ease of use, it’s easy to see why most PAAS members use our FWA/HIPAA compliance program.

Are You Documenting DUR and Submission Clarification Codes?

PAAS National® is continuing to see Express Scripts (ESI) and Tricare flag claims for audit where clinical drug utilization review (DUR) or submission clarification codes (SCC), were submitted. Prime Therapeutics, now processed by ESI, has now joined in. Recoupments are happening due to “No DUR documentation” or “No SCC documentation.” Pharmacies that fail to show documentation of the support codes used on the prescription are facing recoupment.

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Dispensing pharmacists must use professional judgement when receiving a point-of-sale reject. If choosing to dispense a medication using an override code, it is imperative that supporting documentation be placed on the prescription to support its utilization. This documentation should contain detailed information with dates, names, titles, and discussions that took place if patients, or prescribers, were consulted. Lack of this documentation can lead to recoupment.

Most common SCCs subject to audit (as defined by NCPDP) are:

Please click here to view all 37 NCPDP Submission Clarification Codes and their corresponding definitions. There are additional codes found in the link that pertain to LTC billing, compounds and 340B. Drug utilization review codes can be found as follows: Reason for Service CodeProfessional Service Code (NCPDP 440-E5) and Result of Service Code.

PAAS Tips:

  • Make sure all documentation is made on the original prescription or with an electronic note that can be retrieved upon audit request
  • Clinical notations should contain all four elements: date, name and title of person you spoke with, what was discussed and initials/name of pharmacy personnel that made the call
  • Be sure any notations made on previous prescriptions are carried forward to new prescriptions if you are using this as supporting information
  • Documentation should clearly support specific override code(s) submitted
  • Specific information to support vacation supplies and lost medication is recommended
    • For example: date of request, number of days patient will be gone, or amount of medication lost
  • Professional service code “M0” will require consultation with prescriber and appropriate documentation

340B Contract Pharmacy Claims Identification and Submission Requirements

Major PBM Updates Network Provider Manual
For 2021, a major PBM updated their provider manual regarding their position on the 340B drug discount program. Previously stating the PBM encourages Network Providers to identify 340B claims, in 2021 that language was updated to state Providers must identify the claims. This update included a March 1, 2021 effective date for processing what is called N1 (information reporting) transactions. Read the full release.

Webinar: 340B Contract Pharmacy Considerations for 2021

PAAS National® is hosting a webinar on Wednesday, March 3 from 2:00-2:45 p.m. CST

We look forward to you joining us as President of PAAS National®, Trenton Thiede, PharmD, MBA:

  • Reviews 340B audit risk
  • Looks at Medicaid considerations with 340B
  • Reviews the 340B claim identification and submission requirements
  • Discusses the two-tier (aka discriminatory) pricing model
  • Explores a recent PBM communication released on February 24, 2021

Bring your questions, we will do our best to allow some time for Q&A at the end of the webinar.

PAAS Audit Assistance members will have access to a recording on the member portal if you are unable to attend the live event.

Reminder first step to using your audit assistance with PAAS National® is when you receive an audit notice call PAAS 608.873.1342 to get a case set-up then email info@paasnational.com or fax 608.873.4009 in your audit notice.

Our all-inclusive audit assistance membership means there are no hidden fees or limits to the audit assistance you can receive. We are here to help you!

FDA Requests Updated Product Labeling on Insulin Pens

Stop Breaking Insulin Pen Boxes

The pharmacy industry has long debated whether one box of insulin pens is considered “unbreakable”. The debate appeared to be settled January 22nd, 2019 when the U.S. Department of Justice issued a press release stating Walgreens agreed to a $209 million fraud settlement with the federal government regarding its billing and dispensing of insulin pens to Medicaid, Medicare Part D and TRICARE patients. Prior to the settlement, Walgreens’ policy was to not dispense any insulin pens in quantities less than one full box, forcing their staff to falsely understate the days’ supply on thousands of claims. They then enrolled many of these patients on its refill reminder program, causing patients to get early refills. The government labeled that billing activity as
widespread FRAUD and required Walgreens to enter into a Corporate Integrity Agreement with the Office of the Inspector General. Consequently, both Walgreens and CVS have been breaking insulin pen boxes when appropriate. Read the full urgent member alert here.

Caremark Manufacturer Coupon Policy

PAAS National® continues to see pharmacies suffer full recoupment on claims that are processed to coupons and copay cards in violation of Caremark’s policy found in section 3.03.03 of the 2020 Pharmacy Provider Manual. Violations are considered [by Caremark] to be an inappropriate waiver of patient pay amounts and could result in additional sanctions, including termination.

As defined in the current Provider Manual: “Pharmaceutical Manufacturer Coupon” means any item or mechanism, including but not limited to, paper coupons, copay cards, e-vouchers, mail-in rebates, and electronic coupon codes funded by a manufacturer, repackager, or supplier of pharmaceutical, chemical, or compounding products, that reduces the portion of the Patient Pay Amount that an Eligible Person is required to pay for a Covered Item.

Manufacturer coupons may be accepted if:

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  1. Pharmacy complies with all the terms and conditions specific to the coupon – including prohibitions on using for federally funded programs such as Medicare, Medicaid, and TRICARE
  2. The coupon is applied by your pharmacy location and not a hub
  3. The item is NOT a compound drug, 510(k) cleared medical device or Medical Food
  4. The item falls into one of the following categories:

a. Approved as a brand (NDA) or generic (ANDA) drug and published in the FDA Orange Book

b. Approved under a Biologics License Application (BLA) and published in the FDA Purple Book

c. Over-the-Counter (OTC) item marketed under an official final OTC monograph

d. Grandfathered drug marketed before 1938 or 1962, or is otherwise considered Generally Recognized as Safe and Effective (GRASE) by the FDA

PAAS Tips:

  • Pharmacies typically run afoul of Caremark with products sourced from secondary distributors identified as dietary supplements, medical foods or medical devices
    • These are typically products with large patient copays
  • Don’t assume that a product is “FDA approved” just because it has an NDC number
  • Use the following websites to determine FDA marketing status
    • FDA Orange Book
    • FDA Purple Book
    • DailyMed
  • If you are ever in doubt about a product, call PAAS at 608-873-1342 so that we can help you identify whether it will be a problem
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PBM Enforcement of Return to Stock Policies

PAAS National® wrote an article in our April 2020 Newsline regarding PBMs Enforcing Return to Stock Policies. A PBM will recoup a claim in full if a medication is picked up after their required return to stock timeframes listed in the respective provider manuals. The provider manual may reference these as “unclaimed prescriptions.” Pharmacies should have a policy and procedure in place to only allow medications to remain in the will call bins for the shortest outlined time – 10 days. If your pharmacy has PAAS National®’s Fraud, Waste & Abuse and HIPAA Compliance (FWAC) program, a return to stock policy is available to you, including a log to help you document and complete this task (see section 4.1.1 Unclaimed Prescriptions and Appendix B – Unclaimed Prescription Reversal Log).

Major PBM Return to Stock Timeframes:

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Calendar Business
10 days 13 days 14 days 10 days 15 days
MeridianRx
Serve You Rx
TRICARE
Express
Scripts
Aetna
Caremark
Elixir
MagellanRx
MedImpact
Navitus
OptumRx
Prime Therapeutics
Southern
Scripts
Humana

PAAS Tips:

  • Pharmacies should not leave prescriptions in the will call bins for more than 10 days to comply with the shortest return to stock timeline of 10 days per MeridianRx, Serve You Rx and TRICARE.
  • These return to stock timelines also apply to completions (aka “partial fills”) left in the will call bins
  • PBM return to stock policies are still required to be met during the COVID-19 pandemic
  • LTC prescriptions are not exempt from these return to stock policies
  • If you are a FWAC member and change your procedure for returning medications to stock, be sure to have your admin or compliance officer update section 4.1.1 of your Policy and Procedure manual
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