“Unauthorized Refills” Audit Discrepancies; How Does This Happen?

Audit results flagging “unauthorized refills” or “overbilled quantity,” can lead to big recoupments. These discrepancies can take significant time and effort for pharmacies to appeal. PAAS National® wants to help educate pharmacies on why this might be happening on your claims, and how to prevent recoupments.

Many states allow pharmacists to increase the dispensed quantity on a prescription without contacting the prescriber for authorization (check with your state’s allowances to ensure you are complying appropriately). Having documentation to support the reason the dispensed quantity changed from the written quantity is recommended to avoid audit issues. See last month’s Newsline article, Quantity Changes Require Documentation.

Consider the FDA guidance for dispensing insulin pens in the unopened (sealed) carton. Pharmacies can fall into the trap of over dispensing what the prescriber has approved. While this is the appropriate way to dispense insulin pens, pharmacies must be aware how over dispensing can happen. PBM auditors are looking at the total quantity prescribed on the prescription. When a prescription is written for a quantity less than the package size, any increased amount must be authorized by the prescriber or be taken out of the total refill quantity (in states that allow accelerated/consolidated refills).

Here is an example:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Lantus Solostar® written for 9 mL with 3 refills

  1. Pharmacy dispenses a full box (15 mL) to follow FDA guidelines
  2. Prescription is refilled 3 additional times
  3. Total amount prescribed is 9 mL x 4 = 36 mL
  4. Total amount dispensed is 15 mL x 4 = 60 mL
  5. Without a clinical note authorizing the increase in quantity prescribed, the pharmacy over dispensed by 24 mL

Insulin pens are not the only prescriptions to watch, other medications that are dispensed according to package size can also be at risk. Software systems should track this information for you, but only if the data has been entered correctly.

PAAS Tips:

Dana Westberg, CPhT