Walgreens $107 Million Settlement for False Claims Act Violations

A recent Department of Justice press release outlined a settlement with Walgreens for nearly $107 million for False Claims Act violations related to claims billed to government programs that were never dispensed. The government alleges that from 2009-2020, Walgreens restocked thousands of prescriptions billed to Medicare and Medicaid and resold the same medication, effectively collecting payment twice on the same medications.

The underlying cause of the systematic overbilling was related to a feature in Walgreens’ pharmacy management software (Intercom Plus, IC+) where prescriptions which were billed but not sold were removed from the local IC+ servers after 29 days (to save space) and moved into an “Unaccounted-For Status” on the central IC+ server. Pharmacists in the stores could no longer see these prescriptions in the local IC+ work queue and there was no back-end process to reverse the paid claims that were moved into the Unaccounted-For Status. Essentially thousands of billed prescriptions “got lost” and Walgreens received payment for items never dispensed.

In January 2020, Walgreens self-disclosed the systematic error, began to implement corrective actions to resolve the problem, and fully cooperated with the government to settle the overpayments.

Two separate qui tam relators brought this systemic problem to the government’s attention and will receive $14.9 and $1.6 million dollars, respectively.

PAAS Tips:

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  • PAAS suggests that pharmacies perform Return to Stock for any claims not picked up within 10 days of billing
  • PAAS FWA and HIPAA Compliance members can find information about unclaimed prescriptions in section 4.1.1 of their Policy & Procedure Manual
  • Pharmacies with an integrated point-of-sale system should periodically run reports to looking for paid claims that have not been sold to ensure that there are no prescription claims that are “lost” and may result in inappropriate overpayments

Download PAAS’ Return to Stock Chart for detail on PBM specific requirements

FDA Proposed Guidance for Biosimilar Updates

Over the last 10 years, biologics have transformed the treatment of many illnesses like chronic bowel disease, kidney disease, arthritis and cancer and they are the fastest growing class of medications in the United States. The FDA has gained valuable scientific information in reviewing both biosimilar and interchangeable biosimilar medications. They both meet the same high FDA standards and are as safe and effective as the reference product. When the FDA designates a biosimilar product as “interchangeable,” a pharmacist may substitute that product for a biologic without contacting the physician (predicated on state law). This pharmacy-level substitution provides increased access to treatments and cost savings for patients.

However, many pharmacies struggle to understand which biosimilar products can be substituted for the reference product. Consider the following definitions from the FDA:

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  • A biosimilar is a biologic that is highly similar to and has no clinically meaningful difference from an existing FDA-approved biological medication, called a reference product.
  • A reference product is approved in a standalone application that must contain all data and information necessary to demonstrate the product’s safety and effectiveness.

Newly proposed FDA guidance may alleviate this confusion of biosimilar interchangeability.

On June 20, 2024, the FDA issued a draft guidance for industry Considerations for Demonstrating Interchangeability With a Reference Product: Update. The recommendations in the draft guidance would provide clarity and transparency regarding the FDA’s review and approval process for biosimilars. 

The draft guidance eliminates the requirement that biosimilars produce clinical data to show they are interchangeable with their reference product. These clinical trials (switching studies) add time and expense to the development of a biosimilar and delay them from reaching patients.

This update would allow manufacturers who are interested in obtaining a Biologic License Application (BLA) for a biosimilar with a review for interchangeability status to either:

  1. Submit clinical trial data or
  2. Provide a statement indicating why the data in the BLA already demonstrates switching safety
    1. Any other information relevant to support the risk, in terms of safety and diminished efficacy, from alternating or switching between the reference product and proposed biosimilar is not greater than the risk of using the reference product without a clinical trial

Companies with pending BLAs can also submit an amendment to their application including the above information.

While biologic substitution is regulated at the state level, the FDA could broadly increase the number of biologics categorized as interchangeable biosimilars with this draft guidance, making pharmacist driven substitutions more commonplace. PAAS will keep you informed as we await Final Guidance from the FDA.

Self-Audit Series #8: Compound Prescriptions

Compound prescriptions may not be a frequent occurrence for some pharmacies; however, those that do bill compounds must be aware of the audit risks. In addition to a valid prescription, the pharmacy must also have sufficient compound worksheets/logs, and ensure they are billing the claim accurately.

Here is a review what you will need for audit purposes for compound prescriptions:

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  1. Prescription
    1. Must have a valid prescription order that meets all state and federal requirementsMedication that is commercially available is generally prohibited from being compounded by the pharmacy. Be sure you have good documentation if there’s a clinical reason the patient cannot use a commercial product. Shortages can be verified on the FDA website: Drug ShortagesPrescription must clearly indicate each ingredient along with the final concentration prescriber is intending. Avoid using abbreviations or common nicknames (e.g., Magic Mouthwash)
    1. Pre-printed prescription forms are prohibited by many PBMs and should be avoided
  • Compound Worksheet/Log
    • At a minimum your worksheet/log should include:
      • Link to Rx number it was prepared for
      • Formula name, strength and dosage form
      • Date prepared and total quantity made
      • Beyond Use Date (BUD)
      • Each ingredient name, NDC, quantity, lot and expiration date
    • May also consider including:
      • Each ingredient cost (AWP or U&C)
      • Employee name that prepared and approved the compound
      • Documentation for quality control procedures
      • Certificate of Analysis for bulk powders
      • Specific instructions for the compound process
  • Billing for Compounds
    • NDCs billed on the claim must match the NDCs used to prepare the compoundAll ingredients must be included on the claim
      • Do not bypass plan rejects by omitting non-covered ingredientUtilize Submission Clarification Code 08 (Process Compound for Approved Ingredients) when appropriateDo not reduce quantity to bypass any plan rejects due to cost or prior authorization requirementsConfirm pharmacy software is billing accurate quantities for “QS”(quantity sufficient), if needed
      Compounds should only be billed and compounded using USP-NF (United States Pharmacopeia-National Formulary) pharmaceutical grade ingredientsRefer to each PBM Provider Manual for correct Level of Effort (LOE) billing codes
    • Bill an accurate days’ supply based off instructions for use

PAAS Tips:

Audit Risks: Medication Home Delivery

Many independent pharmacies offer unique services to their patients, such as house charge accounts and medication delivery, to provide a better customer experience. While these are convenient services to offer patients, they do bring audit risks if they are implemented without appropriate safeguards.

PAAS National® analyst have seen numerous PBM audit recoupments for insufficient deliveries and discrepancies linked to insufficient evidence of refill request, copay collection, or delivery. Additionally, we have seen audits where the prescriptions were billed for deceased patients.

Review the tips below to ensure that your pharmacy doesn’t incur unnecessary audit risks.

PAAS Tips:

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  • Home delivery tips
    • Require a dated signature from patient/caregiver at every delivery (pre-printed dates on delivery manifests are insufficient)Avoid leaving medications in the mailbox or at the door without evidence of delivery (geotagged photos from pharmacy staff are typically insufficient)Avoid “automatic refills” and instead implement a “medication synchronization” program that includes a telephone check-in prior to medication billing and delivery to ensure that patient is still alive, living at same address, has not been hospitalized since last delivery (or had medication therapy changes), and to confirm the needed medications prior to scheduled delivery date
    • Collect payment at the time of delivery, or implement a robust accounts receivable (“house charge”) process
  • Facility delivery tips
    • Coordinate with LTC facilities to understand if Medicare patients are in a “Part A” versus a “Private Pay” status as this will dictate whether pharmacy is to bill the facility (if Part A) or Medicare Part D (if private pay)
      • Develop written agreements in place that require facility cooperation with retroactive billing changes such as when claims are accidentally billed to Medicare Part D and then subsequently adjusted due to Part A status
    • Pre-printed dates on delivery manifests are insufficient, receiving individuals should handwrite the date received
  • Additional helpful information on house charge accounts can be found in the following Newsline articles:

California Pharmacy Charged in $300 Million Medicaid Fraud Scheme

The US Attorney’s Office for the Central District of California recently issued a press release outlining charges against a pharmacist for the submission of more than $300 million in fraudulent claims to the state Medicaid Program (Medi-Cal) for medications that were not medically necessary, where drugs were not dispensed to patients, and where prescriptions were obtained through illegal kickbacks.

Reportedly, the pharmacy exploited a loophole in Medi-Cal’s claim adjudication process starting in 2022 when Medi-Cal suspended Prior Authorization requirements during a transition to a new payment system. When the pharmacy found this loophole, they began billing for “tens of millions of dollars per month for dispensing high-reimbursement, non-contracted, generic drugs” through the pharmacy claim system. The pharmacy obtained prescriptions through illegal kickbacks and frequently did not even order or dispense the medications involved.

Consequently, it seems Medi-Cal has followed up on this fraudulent activity with more pharmacies receiving extensive invoice audit letters in late July 2024 requesting over three years of invoice records, in addition to dispensing history and financial records (e.g., income statements and balance sheets).

Fraudulent activity from one provider gives payors and PBMs justification to perform additional audits looking for other criminals. Invoice audits often uncover honest billing and documentation errors that can cost you big money – see the tips section below to protect yourself from losses in an invoice audit.

PAAS Tips:

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  • Only purchase drugs from authorized suppliers (Rx and OTC)
    • Remember that OptumRx® requires use of NABP Drug Distributor Accreditation wholesalers
  • Maintain a comprehensive list of your suppliers
  • Ensure that your staff is billing the correct NDC (all 11 digits matter)
  • Reverse prescriptions timely when they are not picked up (return to stock)

Is It Time to Purge? Understanding Record Retention Requirements

The majority of prescriptions filled by pharmacies are based off of an electronically-sent prescription, or “e-script” – 94% according to a 2021 Surescripts National Progress Report to be exact. However, physical hardcopies may still exist in the form of telephone orders, transfers, faxes and written hardcopies. In an effort to free up physical space, amongst other reasons, a common question PAAS National® analysts receive is in regard to how long pharmacies are obligated to retain physical hardcopies of prescriptions, in addition to other physical records. In essence, “PAAS, can I get rid of this yet?”.

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Unfortunately, there is not a straightforward answer. The pharmacy needs to consider a number of things in order to ensure they are in compliance.

Many regulations exist which impact how long records are maintained; inconveniently, they all differ. With that said, the pharmacy must maintain the records to accommodate the longest time period, relieving the pharmacy from memorizing specific regulations. According to 42 CFR §422.504(d) and 42 CFR §423.505(d), two federal regulations governing the CMS Medicare Part D Program, records must be retained for a period of ten (10) years in addition to the current contract year, which includes, but is not limited to, hardcopy prescriptions, signature logs, copay collection and invoices. Since Medicare Part D has the longest record retention requirement, it is PAAS’ recommendation to retain records for 11 years.

Pharmacies need to also consider in which format the records may be stored. As addressed above, electronic transmission is the primary origin of prescriptions. However, there still exists a fraction of prescriptions that pharmacies may have in a physical hardcopy form. It is common for states to have a requirement for hardcopies to be retained in their original form for a period of time before converting to an electronic format.

In the same vein as state-level original format requirements, the DEA has record retention requirements, including but not limited to controlled substance prescriptions, invoices, inventory counts. Controlled Substances must be kept in their original form for two (2) years from the written date. If a pharmacy opts to convert a physical hardcopy to an electronic copy thereafter, it needs to be an exact copy of the front and back of the prescription even if the back of the prescription is blank. 

In conclusion, PAAS urges members to be mindful of how they retain records, whether it is in electronic or physical format. In the case of software changes/crashes/etcetera, ensure there is a backup method to be able to access prescriptions (and other important documentation) in a “readily retrievable” manner. Regardless of the reason, pharmacies are still obligated to respond to audit requests.

PAAS Tips:

  • PAAS FWA/HIPAA Compliance Program members can refer to Section 4.3 of the Provider Manual to ensure that information conforms to your intended practices.
  • Medicaid record retention requirements may be more stringent than state regulations
  • For audit purposes, clinical notations must be retrievable for auditor’s review

How to Submit Your Audit Documents for an Effective Review

PAAS National® analysts continue to see an increasing amount of PBM audits demanding large audit volumes of documents for reviews. Our goal is to help pharmacies respond accurately and efficiently as you submit documentation.

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PAAS analysts review your documents as if we are performing remote pharmacist verification, so it is helpful if we can see both the prescription AND the billing information at the same time.

Upon receiving an audit notice, send it to PAAS. This allows for the analyst on your case to provide guidance from the very beginning of the audit process, which can result in you saving time gathering less paperwork. Additionally, it allows the analyst to provide guidance on what to look for as documents are pulled, such as any electronic clinical notes that need to be added to the hardcopy. This can result in a more efficient, and seamless, pre-audit consult after documents have been reviewed by your analyst, ensuring an effective review for your audit.

General

  • Organize documents in the same order as listed on audit letter
  • If prescriptions/signature logs are requested in two separate “lists”, then separate them in your response (rather than co-mingled)        
  • Include page numbers at the bottom of each page in sequence to ensure no pages are missing and to allow for easy reference if needing to refer an auditor to a contested aspect of your audit.

Prescription Hardcopies

  • Only produce one copy per unique Rx #
  • Only include back of prescription if it has information, otherwise write “back is blank” on the face of the

               hardcopy

  • Include “fill sticker/back slap/backtag” on the front side of the prescription, in the same orientation
  • Make sure clinical notes are visible to support claim as billed
  • Include Patient label (if requested)
  • If any DUR, SCC, DAW or Diagnosis code was submitted, then documentation should include both  the code used and a clinical note to justify its use   
  • Make sure to document on the hard copy if the prescription is a transfer or phoned in order              

Signature Log

  • Only provide for specific date(s) of service when requested
  • Must include at least 3 elements: Rx number, date of dispensing, signature or “COVID-19” (where applicable), some PBM’s require the fill date or refill #
  • Omit PHI for any Rx not subject to audit and be sure to point out the Rx number in question

 Copay Collection

  • Only provide for specific date(s) of service when requested
  • Point-of-Sale transaction receipts with Rx number, copay amount, and method of payment

PAAS Tips:

OptumRx® Provider Manual Updates May Shift Audits – Especially LTC

OptumRx® updates their Provider Manual several times throughout the year and publishes the full version on its publicly available webpage. Since a PBM’s Provider Manual is an extension of their contract, the terms and conditions within the Provider Manual are expected to be followed and non-adherence can cause problems for pharmacies. Such problems may consist of audit chargebacks, fraud, waste and abuse investigations, and even contract termination.

The latest OptumRx® Provider Manual publication is the 2024 Fourth Edition Version 4.1. PAAS National® analysts want you to be aware of the following changes and potential implications it will have on the documents you maintain and provide for an audit as well as changes you may see in your audit results report.

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  • Long-Term Care (LTC) Pharmacy –
    • The following language was removed from the OptumRx® Provider Manual, “Documentation of a valid prescription order shall be comprised of a signed Prescriber’s order and a medication administration record (MAR) for a time period that supports the audited dates of service. All signed Prescriber’s orders must be supplemented by a MAR to help ensure Members are receiving the appropriate therapy and not therapy that has been discontinued or changed since the last Prescriber’s order.
    • What remains is the following, “Network Pharmacy Providers are expected to adhere to these requirements for what constitutes a valid prescription order unless otherwise specified in applicable state laws and regulations. Record retention is important, and timely retrieval of these documents shall be in compliance with audit requirements.”
    • The potential implication of this change is that it may be more difficult to determine the exact requirements for a “valid prescription order” since many states do not specifically delineate LTC order requirements from retail prescription requirements. Previously, the pharmacy could submit the MAR or other facility documents to help validate the prescription order, but those records may no longer carry the same weight as they once did. Many discrepancy codes related to LTC documentation have also been removed from OptumRx’s discrepancy code list since they will no longer be applicable.
  • Discrepancy Code Changes –
Modified Codes
CodeOld DefinitionNew DefinitionImplication
1K   Incorrect use of Dispense as Written Code“Partial Recoupment: reverse and rebill claim with manual cost override at the generic cost (for the brand NDC)”“Recoupment dependent on billing”It remains to be seen if this will be a positive, neutral, or negative change. PAAS analysts have seen recoupment on multi-source brand claims billed with DAW 9 (substitution allowed by prescriber but plan prefers brand) because the plan claimed DAW 0 was appropriate, and the DAW 9 was unsubstantiated. In this scenario, there was no concrete evidence from the PBM to indicate the brand was preferred, therefore the PBM stated the multi-source brand should have been billed with a DAW 0.
1N   Days’ Supply on Claim is Incorrect“Educational”“Recoupment dependent on billing”PAAS analyst have already seen the implementation of this change in audit results, and it definitely has a negative impact on pharmacies. Previously, a claim flagged only with an invalid days’ supply discrepancy would have $0 chargeback. Now, analyst have seen chargebacks, usually in an amount which corresponds to the difference in the patient’s copay once the days’ supply is corrected.
 
Codes Removed
CodeCode DescriptionDefinition
1TUsed smaller size product for larger stock size billedEducational
2FBilled Appropriate No discrepancy adjustmentEducational
3PInvalid RxMissing LTC MAR
3RInvalid RxMissing LTC refill request form
3SInvalid RxMissing patient attestation letter indicating the patient received and consumed the medication
3TInvalid RxMissing LTC facility attestation letter indicating the facility requested/ordered/received the medication
3UInvalid RxMissing LTC nurse as prescriber agent contract

The ever-changing OptumRx® Provider Manual is just another whirlwind which pharmacies are caught in and must learn to navigate. Remember, PAAS is here to help, and our dedicated team is just a phone call, email, or web inquiry away!

PAAS Tips:

Insulin Pens: Understanding Dosing Increments and Audit Risks

PAAS National® continues to see auditors flag insulin pen prescriptions for containing a dosage that does not align with the product. Most insulin pen products can be dosed in 1-unit increments; however, there are some insulin pens that range from 0.5-unit increments to 5-unit increments.

If prescriptions are written with directions that conflict with the dosing of the medication, pharmacies should clarify the directions with the prescriber and make a clinical note on the prescription. For example…

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a prescription written for Toujeo® Max Solostar® with directions indicating 89 units daily must be clarified because the pen can only be dialed in 2-unit increments (i.e., the directions should either be 88 units daily of 90 units daily).

The following table outlines which insulin pens you should pay close attention to when dispensing:

InsulinDosing Increments
Humalog® Junior KwikPen®0.5 units
Toujeo® Max Solostar®2 units
Tresiba® Flextouch® 200 units/mL2 units
Humulin® R U-500 KwikPen®5 units

PAAS Tips:

  • Prescription directions must be clear and follow product dispensing guidelines like dosing increments
  • Clarify any directions that do not follow the specific dosing intervals available for each insulin pen
  • If directions must be clarified, make a clinical note on the prescription and ensure the patient label instructions are also updated
  • Clinical notes should contain:
    • the date you called the prescriber’s office,
    • the name AND title of who you spoke with,
    • a summary of what was discussed, and
    • your initials
  • Download the PAAS National® Insulin Medication chart which contains information on dosing increments as well as other useful information like priming units and beyond use dates, both of which can vary by product
  • The PAAS Rx Days’ Supply Calculator app also contains information on dosing increments and will warn you about instructions that are not compatible with the product. Download the app for a 7-day free trial (only $5.99/year thereafter)

What to Do (and Not Do) When Your Days’ Supply is Rejected

Insurance companies require pharmacies to bill an accurate days’ supply based on mathematical calculations from the directions. Pharmacies should not guesstimate the days’ supply or process every claim as 30 days for simplicity. Not all claims will adjudicate when processing the correct days’ supply, usually due to plan limitations. What should be done in these situations?

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The first step is to make note of any reject messages received when processing for the correct days’ supply. For example, if the insurance limits the quantity to a 30 days’ supply, write “ILQ 30” on the prescription. Then reduce the quantity, if possible, and rebill the claim with the adjusted [accurate] days’ supply based on the revised quantity. Reduce the quantity further if the claim still rejects, until you reach the smallest unbreakable package size.

If the smallest unbreakable package size still does not go through with an accurate day’s supply:

  1. PBMs may provide claim reject messaging to prompt submission of “SCC 10” to allow the true day supply for accurate refill intervals, reimbursement and copays. Document use of this on the prescription.
  2. Call the PBM helpdesk and request an override – document on the prescription if approved or denied.
  3. If no smaller package size exists and PBM can’t (or won’t) issue an override, most PBMs will allow the smallest package to be billed for the maximum days’ supply identified in the original reject message.

If the above process is used, and you processed the claim with an adjusted [inaccurate] days’ supply, you are at risk for early refills because the PBM adjudication logic will allow you to submit a refill claim when the utilization threshold is met based on the previous days’ supply adjudicated, not the actual days’ supply. PBMs still require the pharmacy to monitor utilization and only refill when appropriate based off the accurate [calculated] days’ supply and not the adjudicated days’ supply. Remember, the claim rejection for “refill too soon” will not be appropriately triggered when the pharmacy is forced to bill a smaller days’ supply than the true calculated day’s supply. To help avoid this, PAAS National® suggests documenting the actual days’ supply in the directions for use (e.g., “actual days’ supply=37”) so that it prints on the label to alert staff and patients of the appropriate refill intervals.

Another situation pharmacies run into is when the accurate days’ supply is rejected due to exceeding the plan limit for a maximum daily dose.

For example, a prescription written for OxyContin® 30 mg, quantity 90, with directions to “take one tablet 3x daily” may receive a rejection for “Maximum two tablets per day.”

In this situation, pharmacies should not reduce the quantity to 60 tablets for a 30-day supply (this would be considered bypassing the plan limit). Instead, pharmacies should pay close attention to any messages given on how to resolve the rejection, including calling the PBM help desk for an override or getting a prior authorization started with the prescriber. Alternatively, the prescriber could decide to change the dose or prescribe an alternative medication.

What if the prescriber refuses to obtain a prior authorization or change the prescription to a clinically appropriate dose? Can the claim be split-billed? PAAS National® highly recommends against split billing or processing a claim as cash to circumvent a plan limit or prior authorization requirement. A doctor who refuses to obtain a prior authorization or change the medication/dose could be a red flag for diversion with controlled substances. Most plan limits are put in place based on appropriate clinical use and bypassing them can lead to easy recoupments for PBMs. Pharmacists have a corresponding responsibility to ensure that prescriptions are for legitimate medical purposes, especially for controlled substances.

PAAS Tips:

  • Always bill an accurate days’ supply based on the directions first; many PBMS have overrides in place for the smallest package sizes
  • Only follow the ILQ process above if you are dispensing the smallest unbreakable package size
  • Billing a 30-day supply on two boxes of insulin that should last 50 days is not appropriate. Instead, you must resubmit one box for 25 days if the plan limit is 30 days
  • Include a notation on the patient label to help notify patients and pharmacy staff of the true days’ supply
  • Check with your software vendor to see if additional days’ supply fields are available for internal tracking
  • Avoid med sync or cycle fill programs for products whose correct days’ supply cannot be submitted for the smallest single package size
  • Educate all pharmacy staff to identify rejection messages and how to properly resolve them
  • Any DUR verifications, especially if using “M0” (prescriber consulted) to override the DUR, should have supporting documentation on the prescription or within retrievable electronic records
  • Do not split bill rejected claims
  • Charging the patient cash often leads to complaints [from the patient to an employer or PBM] and can be considered non-compliance with the provider manual and lead to remediation, including potential network termination
  • If you have exhausted all plan options (including pursuing PAs and/or alternative therapies) and the patient insists on paying cash for the full prescription, be sure that you document authorization from the patient that they desire to pay the full cost and will not seek reimbursement from the insurance.
  •  Review our Can You Bill It As 30 Days? document under Proactive Tips on the Member Portal