Quantity Changes Cause Audit Appeal Trouble

PAAS National® is seeing more discrepancies for “unauthorized” refills on audits and PBMs continue to make these discrepancies difficult to appeal.

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For example, Humana only allows electronically stored date and time stamped pharmacy notes validating the increase in quantity and/or refills (and the date authorized). Similarly, OptumRx will only accept a prescriber statement on appeal for unauthorized refills if the causality is not an undocumented/unapproved increase in quantity.

What is considered an “unauthorized refill?” Examples include:

  • Dispensing a quantity larger than written without documented prescriber approval.
    • If a prescriber writes for 3 mL on an insulin pen, you cannot simply increase the quantity to 15 mL to dispense a full box.
  • In states where consolidating refills without prescriber approval is allowed, you cannot dispense more than the total original quantity and refills written without consulting with the prescriber.
    • If a prescriber writes for 3 mL plus 2 refills on an insulin pen, you can only dispense 9 mL total without consultation with the prescriber.
  • Transfer prescriptions need to be entered carefully. Pay close attention to “total fills remaining” vs “1+x refills remaining.”
  • Pay attention to electronic prescription fields of “authorized fills” vs “refills” as discussed in our October 2020 Newsline article, Are You Overbilling? Refills vs Authorized Fills.
  • Having a clear unit of measure on a written quantity prevents confusion.
    • If a prescriber writes for 15 “unspecified” for a quantity on an insulin pen, an auditor may argue it is unclear if the prescriber meant 15 mL, 15 pens, or 15 boxes.
    • If a prescriber writes for a quantity of “1” on inhalers, topical medications, or eye drops, the auditor will assume the smallest package size even if that is an institutional size pack not regularly dispensed by retail pharmacies.
    • If a prescriber writes “one month” for a quantity, ensure your days’ supply is NOT more than 30 days. For example, an insulin pen written for 45 units daily and a one-month supply has an actual days’ supply of 33 not 30. This quantity should be clarified to ensure over-dispensing does not occur.

In all the above cases, good documentation is key to avoiding audit discrepancies. It is preferable to have date and time stamped electronic notes at the time of dispensing. Check with your software vendor about your system’s capabilities.

PAAS Tips:

  • Ensure documentation is consistent and thorough when handling quantity changes
  • Clarify any ambiguous quantities or unspecified units of measure with the prescriber
  • Be sure your transferred prescription refills are entered appropriately. See our June 2022 Newsline article, Best Practice for Entering Transfers with Partial Refills Remaining
  • Understand the nuances of refill wording and how this can affect claims
  • When contacting the prescriber about changing or clarifying quantities or refills, be sure you document the prescription with a complete clinical note
    • A complete clinical note includes the date, name and title of who you spoke with, summary of what was discussed, and pharmacy employee initials
  • See our October 2022 Newsline article, “Unauthorized Refills” Audit Discrepancies; How Does This Happen? for more information on unauthorized refills

Jenevra Azzopardi, CPhT