PAAS has received numerous questions related to split-billing opioid prescriptions to insurance and cash. The current state of the opioid crisis has made these claims targets for audit recovery and DEA scrutiny.
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against split billing or processing a claim as cash to circumvent a plan limit or prior authorization requirement. Most limits are based on appropriate clinical use. Bypassing these edits for opioids can lead to overdoses, diversion, and even death. Especially for controlled substances, pharmacists have a corresponding responsibility to ensure that prescriptions are for a legitimate medical purpose
21 CFR 1306.04(a).
PAAS Tips:
- PBMs will monitor and flag claims that are rejected for plan limits and reprocessed with changed quantity and/or days’ supply
- Claims will be recovered in full if billed with the wrong days’ supply and exceed plan limits
- For example, Oxycontin 30 mg #90 1 po TID, plan limit 2/day: billing #60 as 30 days’ supply is incorrect for TID dosing and will likely be recovered in full
- PBMs may have access to state prescription drug monitoring programs (PDMPs) to look for cash claims
- Charging the patient cash can be considered non-compliance with the provider manual and could 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 are willing to pay the full cost and will not seek reimbursement from the insurance. This may protect you from accusations of non-compliance.
- Multiple transactions on the PDMP may raise red-flags for state and DEA agents as a possible diversion
- Always call for an override or prior authorization. Most edits can be overridden with appropriate clinical documentation
- Obtaining prior authorization can often resolve the problem for six months to a year
- 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
- Don’t be afraid to enlist the patient’s help. Having them file a complaint with their insurance can help expediate the PA approval process.
