definition of fraud vs. abuse - home - northeast pharmacy€¦ · maintain sound filing practices...

Samantha Allard OSD Consultant and Project Manager

The Connecticut Department of Social Services in Partnership with the UCONN School of Social Work

Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW

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version 1.3 - 7/6/2017

At the end of this training participants will have a better understanding of:

The purpose of an audit

The audit process

Preparation for an audit

Common errors found during audit

How to appeal an audit decision


TODAY’S GOALS

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PURPOSE OF AN AUDIT

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Audit is a formal review to ensure that Medicaid payments are:

For covered services that were actually provided, properly billed and documented.

To ensure that claims were paid according to Federal and State laws, regulations, and policies.

DSS Quality Assurance Medicaid Audits are conducted as required by Conn. Gen. Stat. § 17b-99(d)

U.S.C. – United States Code (federal statutes)

Conn. General Statutes

C.F.R. – Code of Federal Regulations

Regulations of CT State Agencies

Pharmacy Provider Manual

Provider bulletins


MEDICAID POLICY

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No- Auditors enforce policy.

During an audit if questions regarding the interpretation of policy arise then the policy division is consulted for clarification.


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DOES THE AUDIT DEPARTMENT WRITE POLICY?

YES- The State Medicaid Program is audited by:

DHHS OIG performs audits of the Medicaid federal share.

CMS performs audits as part of the PERM review

State auditors audit the State Medicaid program.


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DOES THE STATE MEDICAID PROGRAM GET AUDITED?

Payment for duplicate items

Payment for non-covered services

Payment that should have been paid by a third party

Pricing errors

Data entry errors

Lack of documentation

Insufficient documentation

Number of unit errors

Policy violations

Administrative errors


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IMPROPER PAYMENT ERRORS

To determine whether:

Services were rendered to an eligible recipient

Claims properly reflect the services rendered

Original documentation was maintained to accurately evidence the services provided

Claims were submitted in accordance with Department policies, regulations, provider manuals and bulletins


OBJECTIVE OF AN AUDIT

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Goal: Establish internal controls to decrease providers’ risk of practices that result in errors.

Review and adhere to standard procedures and regulations outlined in your provider manual and provider enrollment agreement

Maintain sound filing practices

Conduct your own internal audit of random claims

Conduct effective training and education

Maintain open lines of communication with staff


COMPLIANCE PROGRAM

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Helps identify and correct documentation and billing issues before submitting claims

Allows for identification and correction of issues before they become a problem

Puts provider in a better position to respond to an audit


BENEFITS OF COMPLIANCE PROGRAM

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Adjust claim if overpaid or underpaid

Adjust claim when information on a paid claim is incorrect ie; client ID, NPI, date of service

**Adjustments should not be made to claims that are part of an open audit.


CLAIM ADJUSTMENTS

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PHARMACY AUDITS CONDUCTED BY DSS

Provider Selected by DSS

Universe of Claims Forwarded to Statistician


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AUDIT SAMPLE

Sample Selected Based on Statistically Valid Sampling Methodology

Samples Forwarded to DSS via Secure Server


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Review your audit notification

Have records easily accessible

Have the appropriate personnel available


AUDIT PREPARATION

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Audit Location

Onsite Audit – Auditor may go to multiple locations dependent on the selected samples

Once auditor is onsite, the provider will be given a list of claims to be reviewed


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DAY 1 AUDIT


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Common Error: NPI submitted on the claim to identify the prescriber does not match the NPI on the original hard copy prescription.

Appropriate Procedure: Verify NPI on the claim matches NPI on prescription. NPPES can be used to search for provider NPI.

Exception: Certified pharmacists may use his/her NPI as prescribing provider to dispense naloxone (Narcan)


BILLING – PRESCRIBER’S NPI DOES NOT

MATCH THE CLAIM

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Common Error: Primary TPL EOB is not documented or the amount paid on the TPL EOB does not match the amount on the Medicaid claim.

Appropriate Procedure: Maintain TPL EOB for 5 years and submit copy when audited. Verify amount shown as paid by TPL on the EOB is the same as the amount submitted on the Medicaid claim. If they are different submit a corrected claim.


BILLING - PRIMARY TPL EOB NOT DOCUMENTED OR SUBMITTED INCORRECTLY

ON CLAIM

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EXAMPLE:

*

Common Error: The quantity dispensed is different then the quantity on the claim.

Appropriate Procedure: If more than one dispensing is needed, ie: due to limited supply, then provide documentation showing the dispensing of the remaining quantity owed.


BILLING - QUANTITY DISPENSED DOES NOT MATCH QUANTITY ON CLAIM -

PARTIAL FILL

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EXAMPLE:

Common Error: Days supply indicated on the claim is not correct based on the original prescription. Example: Rx for 5 mls Lumigan indicates 50 day supply; however, the claim submitted indicates 15 day supply. Rx on 12/1/14 and again on 12/14/14 (early refill).

Appropriate Procedure: Verify that the days supply submitted on the claim is the same as on the original prescription.


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DOCUMENTATION – DAYS SUPPLY RESULTING IN AN EARLY REFILL


DOCUMENTATION - COUNSELING OFFER NOT DOCUMENTED OR INVALID FOR

DATE OF SERVICE

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Common Error: Offer to counsel is not properly documented.

Appropriate Procedure: Provide documentation that supports the offer to counsel was made for all initial and refilled prescriptions.

Common Errors: “Brand Medically Necessary” was not written on the prescription to substantiate the DAW1 code submitted on the claim.


DOCUMENTATION - DAW1

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Appropriate Procedure: Claims submitted as DAW1 should have:

Paper prescription: “brand medically necessary” in doctor’s handwriting

Electronic prescription: proper DAW1 code

Telephonic prescription: pharmacist must specify “brand medically necessary” or “no substitution” on prescription in his/her handwriting along with the time of authorization and name of person who communicated the authorization, written verification must be received within 10 days.


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DOCUMENTATION - DAW1

Non-compliant Compliant


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EXAMPLE:

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Common Error: Documentation of delivery could not be substantiated.

Appropriate Procedure: Tracking numbers and/or proof of delivery should be available to verify proof of delivery of claims that are delivered or shipped.


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DOCUMENTATION – DELIVERY NOT DOCUMENTED

Common Error: Diagnosis is required and indicated on the claim submission; however, it is not found on the original hard copy prescription.

Appropriate Procedure: Pharmacist can enter diagnosis on the prescription after verification with the prescriber.


DOCUMENTATION - DIAGNOSIS CODE

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Common Error: Directions on the prescription record concerning dosage and frequency do not match directions on the original prescription.

Appropriate Procedure: Dosage and frequency directions on the prescription match those given to the patient on the prescription record.


DOCUMENTATION - DIRECTIONS DO NOT MATCH PRESCRIPTION SIG

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EXAMPLE:

Prescription

Prescription Record

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*

Common Error: NDC is obsolete or terminated. NDC on the claim doesn’t match dosage form or strength on the prescription.

Appropriate Procedure: Verify that a current NDC is being submitted on the claim. When searching by drug name verify that the strength, dosage form and package description of the NDC match what is on the claim.


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DOCUMENTATION/SERVICES – INCORRECT DRUG/NDC

Common Error: The most cost effective single or combination of strengths was not dispensed. Example: Prevacid dispensed at 90 x 15 mg solutabs; however, the most cost effective (cost per pill) single or combination of strengths are 30 x 15mg and 30 x 30mg Solutabs.

Appropriate Procedure: Ensure that the most cost effective strength is dispensed.


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DOCUMENTATION/SERVICES –

MEDICATION WASTE/OVERPAYMENT

Common Error: Prescriber’s signature is missing or invalid on a written prescription. Faxed prescriptions with rubber stamp (not handwritten).

Appropriate Procedure: Provider should attain new prescription with a signature or verbally verify with the prescriber.


DOCUMENTATION - PRESCRIBER SIGNATURE MISSING OR INVALID

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Common Error: Prescription is refilled more than authorized based on the refills indicated on the original prescription. Refill is rolled over to a new prescription number without authorization from the prescriber.

Appropriate Procedure: Authorization to refill the prescription must be obtained from the prescriber if all refills have been used.


DOCUMENTATION - REFILLS

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Common Error: Original prescription not supplied.

Appropriate Procedure: Maintain all documentation supporting the claim.


DOCUMENTATION - RX MISSING

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Common Error: Handwritten or computer generated and printed prescription does not contain at least one industry recognized feature from each category:

1) Feature to prevent unauthorized copying of a completed or blank prescription

2) Feature to prevent erasure or modification of information written on the prescription

3) Feature to prevent the use of counterfeit forms


DOCUMENTATION - TAMPER RESISTANT

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Appropriate Procedure: If prescription does not meet tamper resistance requirements, then contact the prescribing provider. During audit provide documentation supporting the prescribing provider was contacted to validate the prescription.


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DOCUMENTATION - TAMPER RESISTANT

Common Error: Quantity dispensed was greater than the quantity ordered.

Appropriate Procedure: Any change in quantity dispensed should have:

Reason for the change

Name of person authorizing the change, verify with prescriber and document call

Pharmacist name or initials and date notated on the hard copy prescription


SERVICES - DISPENSING QUANTITY GREATER THAN ON PRESCRIPTION

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Common Error: Quantity dispensed is less than ordered on the prescription.

Appropriate Procedure: Quantity dispensed should match the quantity ordered on the prescription.


SERVICES - DISPENSING QUANTITY LESS THAN ON PRESCRIPTION

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EXAMPLE:

Prescription

Claim

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Common Error: Generic is written on the prescription; however, dispensed with a brand medicine that is not on the preferred drug list.

Appropriate Procedure: Dispense generic if it is written on the prescription, unless directed by the Department to fill as brand per preferred drug list.


SERVICES - GENERIC WRITTEN FILLED BRAND NOT ON PDL

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Common Error: Prescription, or refills, dispensed after 12 months from the date written by the prescriber. (6 months prior to 8/1/15) *Does not apply to items under the Controlled Substance Act which are allowed 5 refills or up to 6 months whichever comes first.

Appropriate Procedure: If prescription or refill is requested beyond the 12 month date of issuance then a new prescription should be requested.


SERVICES - PRESCRIPTION FILLED GREATER THAN TWELVE MONTHS FROM THE DATE

WRITTEN

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Outstanding Documentation List Given to Provider

Provider has opportunity to submit missing documentation

Errors are Reported to Statistician

Statistician Calculates Extrapolation


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CLAIM REVIEW COMPLETE

As provided under statute 17b-99(d) examples of errors that may not be extrapolated:

Payment or billing errors resulting from the transition to a new payment, billing or accounting system


EXTRAPOLATION

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Statutory extrapolation threshold = 1 ¾% of total claims paid for the audit period

If extrapolated error amount exceeds the statutory extrapolation threshold, then financial overpayment is the extrapolated error amount

If extrapolated error amount does not exceed the statutory extrapolation threshold, then financial overpayment is the sample error amount


STATUTORY EXTRAPOLATION THRESHOLD

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Overpayment Due = Extrapolated Amount

Overpayment Due = Sample Errors

Total claims for audit

period $100,000 $500,000

% applied to total paid

claims 1.75% 1.75%

Calculated

extrapolation

threshold

$5000 > $1,750 $5000 < $8,750


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EXAMPLE: EXTRAPOLATED ERROR AMOUNT =$5000


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Written request for hearing

No later than 30 days after final report received

Request must contain detailed description of each specific item of aggrievement

Final decision based on hearing

Appeal of final decision to Connecticut Superior Court


APPEAL PROCESS

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DSS Website – Audit Protocols www.ct.gov/dss

HMS – status of TPL 866-277-4271

DXC Provider Assistance Center 800-842-8440

Pharmacy Prior Authorization Assistance Center 866-409-8386

DSS Map www.ctdssmap.com

Provider Manuals (Enrollment & Re-enrollment, policy, claim submission instructions)

Bulletins (Can search by provider type)

Pharmacy Information Section

Preferred Drug List

Pharmacy Program Publications


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IMPORTANT DSS RESOURCES

http://www.ctdssmap.com/

Dept. of Consumer Protection – Drug Laws and Regulations www.ct.gov/dcp/cwp/view.asp?a=1620&Q=275966&PM=1

U.S. Dept. of Justice – DEA www.deadiversion.usdoj.gov/index.html

State of CT Statute www.cga.ct.gov/lco/statutes.asp

State of CT Regulations https://eregulations.ct.gov/eRegsPortal/


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IMPORTANT REGULATION RESOURCES

http://www.ct.gov/dcp/cwp/view.asp?a=1620&Q=275966&PM=1

http://www.ct.gov/dcp/cwp/view.asp?a=1620&Q=275966&PM=1

http://www.deadiversion.usdoj.gov/index.html

http://www.deadiversion.usdoj.gov/index.html

http://www.cga.ct.gov/lco/statutes.asp

https://eregulations.ct.gov/eRegsPortal/


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