Easy Audit Recoupment Prevention: Document Changes in Quantity Dispensed

PBMs have attempted to recoup claims where the quantity dispensed was decreased or increased from the quantity prescribed when there was a lack of documentation to substantiate the change. PBMs may believe pharmacies are trying to accumulate more dispensing fees or bypass plan limits when pharmacies are dispensing a smaller days’ supply compared to what was prescribed. Conversely, if state law and/or prescriber approval allows, increasing the quantity dispensed puts the pharmacy at risk for exceeding the total amount prescribed by the doctor.

Additionally, pharmacies need to be mindful about their contractual obligations with PBMs. As discussed in the September 2022 Newsline article Prescription Quantity Changes Require Documentation, PBMs may have extended days’ supply agreements laid out in their contracts with pharmacies, requiring them to make “commercially reasonable efforts” to dispense more than 30 days’ supplies on medications. As a result, lack of documentation could lead to a situation that PBMs believe the pharmacies are violating their contracts and could end up with decreased reimbursement or required corrective action plans.

Fortunately, the documentation required does not need to be elaborate. A clinical note that contains “patient requests 30 days’ supply” or “medication synchronization patient” to explain the decrease in quantity dispensed should suffice. If prescriber approval is obtained and/or your individual board of pharmacy gives pharmacists the authority to increase, a clinical note with “prescriber approves 90 days’ supply” or “increased quantity per state regulation xx.xx” to explain the increase in quantity dispensed are examples of acceptable documentations.

Here are some additional considerations and PAAS Tips when changing the quantity dispensed:

Decreasing Quantity Dispensed

• If the medication is required to be dispensed in its original container per packaging requirements, document “per manufacturer, must be dispensed in original container”
• Changing the quantity to circumvent a plan limit or negative reimbursement are not valid reasons to dispense a quantity less than prescribed and could result in full recoupment of claims or a contract violation that may warrant further action

Increasing Quantity Dispensed

• If your state law allows for the quantity dispensed to be increased independent of prescriber approval, document “increased to 90-day supply per state regulation xx.xx” with a date and pharmacist initials
• If your state law requires the prescriber to be contacted for approval of an increased quantity to be dispensed, ensure you make a clear clinical notation that includes the date of the correspondence, name and title of the individual who you spoke to, message communicated, and your initials
• Be mindful of the total quantity prescribed on prescriptions since you cannot dispense over that total amount over the life of the prescription.
  • For example, consider a prescription that was written for a quantity of 3 mL with 4 additional refills. The total quantity prescribed is 15 mL. Therefore, if your pharmacy does not break insulin boxes (which remains PAAS’ guidance at the time of this publication), you are only able to dispense the one full box with no additional refills. Pharmacies have the following options:
    • Dispense the full 15 mL and send a refill request to the prescriber for a new prescription on the next fill (assuming your state allows for the pharmacist to increase the quantity dispensed; and they have documented accordingly)
    • Contact the prescriber to verify the quantity and refills on the prescription and document on the hardcopy via a clinical note