Plan limit rejections are intended to help control costs, provide clinical edits, and assist pharmacies in ensuring patient safety. When an initial claim adjudication is rejected for exceeding plan limits (e.g., Max Quantity Limit or Quantity vs Time Limit), pharmacies need to proceed with caution. An order entry technician that subsequently rebills for a different quantity [and same days’ supply] or the same quantity [and different days’ supply] than originally submitted, is asking for that prescription to be audited. PBM analytics assume the original adjudication was submitted and rejected [accurately] and when a subsequent claim [typically within seconds] has an altered quantity or days’ supply, it’s suspected that the manipulation was done [inappropriately] to get a paid claim. How should pharmacies proceed?
When rejections like these happen, pharmacies need to 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. The prescriber could also decide to change the dose or prescribe an alternative medication.
Some examples of the INCORRECT way to handle rejections that have led to audits and recoupments:
- Test strips, #350 strips, with directions to “use up to 9x daily as needed.” The pharmacy received a rejection stating the plan only covers up to 8x daily. The claim was reprocessed for #350 strips for an incorrect 44-day supply resulting in potential recoupment for bypassing the plan limit.
- Oxycontin 30 mg, #90 tablets, with directions to “take 1 tablet 3x daily.” Plan limit rejection received for “Maximum 2 tablets per day”. The pharmacy reduced the quantity to #60 tablets and billed an incorrect 30-day supply resulting in potential recoupment for bypassing the plan limit.
What happens if a prescriber refuses to obtain a prior authorization or change the prescription to a clinically appropriate dose? Can the claim be split-billed? PAAS National® 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 dose could be a red flag for diversion with controlled substances. Remember that most plan limits are put in place based on appropriate clinical use and bypassing them can lead to overdoses, diversion, and/or death. Pharmacists have a corresponding responsibility to ensure that prescriptions are for legitimate medical purposes, especially for controlled substances (21 CFR 1306.04(a)).
- Always bill for the accurate days’ supply based on the quantity and the directions given on the prescription
- Educate all pharmacy staff to identify rejection messages, how to properly resolve them, and to never purposely input the incorrect days’ supply or quantity to get a paid claim
- Obtaining a prior authorization can often resolve the problem for six months to a year
- Alternatively, the prescriber could send a new prescription [or verbally authorize] for a clinically appropriate dose or change in medication
- Prescribers that are unwilling to obtain prior authorization or to change the prescription to a clinically appropriate dose may be a red flag for diversion with controlled substances
- You may need to call the PBM help desk for assistance processing a claim or obtaining a proper override
- 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
- Use a proper clinical note when speaking with the prescriber’s office or help desk which includes the date, name and title of who you spoke with, what was discussed, and pharmacy staff initials
- 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 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. This may protect you from accusations of non-compliance
- Don’t be afraid to enlist the patient’s help. Having them file a complaint with their insurance can help expediate the prior authorization approval process
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