1. Keeping the Audit Hounds at Bay
Ways to Successfully Prevent and Ace an Audit

2. Disclosure Statement Eileen Fournier & Kathy McIntyre
Presenters have no conflict of interest to disclose
Speaker’s presentation of this slide indicates agreement to abide by the non-commercialism guidelines provided in the CE Requirements page
The information provided in this presentation is true and accurate to the best of our combined experience and knowledge

3. Oh no! Not another audit!
Have you ever thought this when Corporate sends you another notice that your pharmacy will be audited soon?

4. What products are most audited?
What triggers those audits?
What products are most audited?
And more importantly how can you avoid or pass the audit when it comes?

5. Audit Triggers…

6. Quantity and Day Supply …
Overbilled quantity is the biggest offender in audits
What is an overbilled quantity?
Quantity billed exceeds the amount authorized by the prescriber, or
Quantity dispensed exceeds the day supply submitted, or
Quantity exceeds what the plan allows

7. What products are big offenders?
Topical medications (creams / ointments)
Ear / Eye drops
Triptans
Insulin
Expensive kits like Humira, Copaxone, etc.

8. Use as Directed… ‘Use as directed’ SIGs are another dangerous avenue
What forms can a ‘use as directed’ SIG take?
‘Per sliding scale dose’
‘As needed for migraine’
‘Per prescriber’s orders’

9. Ways to combat the dreaded ‘Use as Directed’ SIG…
UAD
Contact the prescriber for complete instructions
Ask the patient
(be careful to document information from the patient away from the prescriber’s SIG and do not type it on the label)
Getting a max dose per day from either the prescriber or patient

10. True or False…
When the patient gives you the max dose or area to be treated it’s best to include that information in the SIG.
FALSE

11. The BIG offenders…
Details on ways to figure out day supplies when filling these products…

12. Topicals – creams / ointments
Ask the prescriber or patient for area or size of area
Use the fingertip unit to determine the day supply
Look at patient filling history
Always use the smallest size available

13. What is the fingertip unit?
From the tip of your index finger to the first joint is considered 1 fingertip unit

14. Now it‘s your turn…
Measure out 1 fingertip unit & apply it to your hand…
Does that amount cover the front and back of your hand?

15. Ear & Eye Drops… 15 to 20 drops per ml is the standard range
Some insurances will allow 15 drops per ml to allow for human error
Always dispense the smallest size bottle available
For emergency prescriptions that the patient must start right away:
If you only have a large size bottle document that the patient could not wait for a smaller size to be ordered on the hard copy

16. Show me the math… Prescription reads as follows:
Drug: PREDNISOLONE AC 1% EYE DROP
SIG: INSTILL 1 DROP INTO BOTH EYES 4 TIMES DAILY
Order Quantity: 5ml
What would the day supply be?

17. Answer… 5ml X 15 drops 75 total drops And… 1 drop into each eye
X 4 times daily
8 total drops per day
So…
75 / 8 =
9.375 or 9 day supply

18. True or False…
The easiest way to determine a day supply for an ear or eye drop is to use the fingertip unit method.
FALSE

19. Triptans… Easy target for auditors
Most insurance companies look to the drug manufacturers for dosing guidelines.
4 headaches in a month is the typical guideline for these medications
Package inserts will state, “The safety of treating an average of more than 4 headaches in a 30 – day period has not been established” (Imitrex Package (GSK) Insert 2.1 ‘Dosing Information’)
Billing for 4 migraine episodes in a 28 day period is a good rule of thumb

20. What to do if the patient has more than 4 migraines in a 28 day period…
Document how many headaches the patient suffers from monthly
From the patient
From the prescriber
The insurance may also require a prior authorization

21. Insulin… Use as directed type SIGs are very common for insulin
Remember
a sliding scale SIG does not give enough information
Asking for the max daily units will help determine the day supply
Questions to ask when calculating the day supply:
How many total units are in a vial or pen?
How many total units is the patient using daily?
How long will the vial or pen last once it has been opened?

22. D
Multiple Choice…
A prescription comes in for 3 vials of insulin with the directions of ‘use per sliding scale directions’. How should you calculate the day supply?
Use a 30 day supply as this is the max day supply the insurance will allow
Consult the magic 8 ball you have on hand at all times
Only dispense 1 vial for a 28 day supply
Contact the prescriber or ask the patient for their max daily units and calculate the day supply using that information.

23. Expensive Kits Make for Easy Targets…
Humira
Humira
Copaxone
Copaxone
Enbrel
Enbrel

24. Make sure you are billing the correct pack size…
Look carefully at the way your computer system has the pack size set up for each kit.
If you are unsure if it is set for the whole kit or single dose compare it to your supplier invoice.
Make sure you are billing the correct day supply
Example:
Copaxone kit normal dosing used to be billed as quantity 1 for a 30 day supply
Now normal dosing is billed as a quantity of 30 for a 30 day supply.

25. Watch out for loading doses…
Make sure you take in account the loading dose on the first fill and remember not to include it on subsequent fills
Vagifem - another medication with a loading dose that often is billed incorrectly on subsequent fills
Create 2 prescriptions
1 for the first month or fill which includes the loading dose with no refills
Another for the refills for the continuation of therapy

26. Other Third Party Findings…

27. Early Refill / Refill Too Soon Overrides…
Document the reason for the refill too soon override
For vacation override
Date of departure
Date of return
Lost or stolen medication
Copy of police report may be required

28. DAW codes… X – DEA #... Is it being used for pain or opiate addiction?
Make sure you are using the correct DAW code
Document on the hard copy reason for DAW code being used
How many use a DAW 9 when billing OR Medicaid?
X – DEA #...
Is it being used for pain or opiate addiction?
Do you have the X-DEA # written on the hardcopy if it’s for opiate addiction?
Do you have “for pain” in the SIG if it’s not for opiate addiction?

29. Isotretinoin Prescriptions…
Make sure you have on the hard copy
The RMA #
And the pick up by date
RMA #
P/U by 11/1/2014

30. And finally the best advice we can give is…
Document!
Document!
Document!
Document!
Document!
And finally the best advice we can give is…

31. Preparing for a Successful Audit…
There are several important things to remember and consider when you are preparing for an audit:
Make sure that all licensing is current and displayed.
Pharmacist and Technician Licenses
State Board License
DEA License

32. The auditor should provide you with a date range at the time you receive your audit notification of the claims that will be review.
Make sure that all prescriptions are available in store for the date range given
Some auditors, but not all, may provide a masked list prior to the audit date.
However you file your hard copy prescriptions, make sure that they are available for viewing.
It’s best to have your controlled substance prescriptions copies readily available.
Some auditors seem to be ok viewing the non-controlled prescriptions in the computer system.

33. Make sure to schedule a HIPAA trained staff member to help assist the auditor during the audit.
This can make your audit go smoother and faster.
It also allows quicker responses if the auditor is requesting additional documentation as in:
notes in the patient files,
pulling prescriptions copies
printing screen prints
It’s good to provide extra space in your pharmacy, such as a back counter, so that the auditor has room to work.

34. Verify who is entering your pharmacy
Check their ID badge
Have them sign in and out of your pharmacy per HIPAA regulations
You may be asked additional questions during or at the end of audit, such as:
Policy and procedure questions (i.e. return to stocks)
Staff training for HIPAA and FWA
The auditor may want to go over their findings, discrepancies with the pharmacist.

35. Ask questions… This is a great time to pick the brain of an auditor
And be sure to share what you learned during the audit with your team!

36. And above all…
RELAX!