Auditors Become Increasingly Stringent on Quantity and Unit of Measure Appeals

“Humana only allows electronically stored date and time stamped pharmacy notes validating the increase in quantity and/or refills (and the date authorized)…OptumRx will only accept a prescriber statement on appeal for unauthorized refills if the causality is not an undocumented/unapproved increase in quantity”. Six months later, PAAS has now learned that OptumRx will no longer accept prescriber statements as a means of appeal for “unauthorized” refills. As a result of the decreased tolerance for quantity and unit of measure errors, it is important to ensure each are correctly documented from the beginning.

“Unauthorized refills” are instances where a pharmacy dispenses a quantity of medication that exceeds the total written quantity of the prescription, whether that be in a single fill or over the lifetime of the prescription.

Example of a Prescription Received Electronically: Insulin glargine pen injector is prescribed with a written quantity of “3 unspecified” with 4 additional refills.
Scenario #1: No clarification notated on hardcopy/electronic notes field	The auditor may assume the smallest amount, which would be 3 mL in this example. Therefore, they believe the total written quantity of the prescription to be 15 mL. If the pharmacy interprets “3 unspecified” to be “3 boxes” (e.g., based on the sig), the total written quantity the pharmacy believes they have would be 15 boxes, or 180 mL. Assuming the pharmacy does not break boxes, each fill would face full recoupment.
Scenario #2: Pharmacy crosses out “unspecified” and writes “boxes”	There is a high probability the auditor will take issue with the lack of documentation, although it is lower in comparison to Scenario #1. They would want to see a full clinical note showing the prescriber or their agent clarified the prescribed quantity. As a reminder, a clinical note includes who you spoke to including name and job title, what you spoke about, when the conversation occurred, and your initials.
Scenario #3:  Pharmacy calls prescriber and notates in the clinical note “Per Julie RN, Approved dispensing #15 mL 01/01/2001 RPH”	Although the risk of recoupment is decreased due to the presence of a clinical note, there is still the possibility of the prescription being marked discrepant due to “unauthorized refills”. The auditor may interpret the clinical note to mean the pharmacy is allowed to dispense a #15 mL box of insulin according to the conversation with the prescriber’s office, but still assume the prescription to be 3 mL with 4 additional refills, using up the entire written quantity on the first fill. Any additional refills beyond the initial date of fill would face full recoupment.
Scenario #4: Pharmacy calls prescriber and notates in the clinical note “Per Julie RN, Prescription to be written as 3 boxes with 4 additional refills 01/01/2023 RPH”	The risk of the prescription being marked discrepant due to unauthorized refills is greatly reduced. The quantity and unit of measure is clearly notated and there is no question of what quantity is remaining on the prescription.

PAAS Tips:

• Refer to September 2023 Newsline article, Easy Audit Recoupment Prevention: Document Changes in Quantity Dispensed to ensure your pharmacy is properly documenting increases and decreases in dispensed quantity compared to written quantity.
• Refer to this month’s article, Insufficient/Missing Clinical Notes Yield Audit Recoupments
• Follow your state regulations regarding pharmacy-level ability to consolidate refills
• In cases of transfers, be intentional when notating the quantity of medication remaining on the prescription
• If a prescription is written for a quantity of “1” on inhalers, topical products, or eye drops, the auditor will likely assume the smallest package size, even if it is an institutional size package that is not regularly dispensed by retail pharmacies
• If a prescription is written for a “30 days’ supply”, the auditor will assume the doctor wrote for an amount that is exactly 30 days, even if that quantity is not feasible, such as a fraction of an insulin pen