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Pharmacy bill format for R&D

Welcome to the "Pharmacy Self- Auditing: Control Practices to Improve Medicaid Program Integrity and Quality--Module 4: Billing Practices" presentation. In module 3 we discussed the third component of the self-audit process, invoice management. We reviewed various approaches to validating wholesale invoices and ways in which drug claims can exceed purchases. Finally, we discussed times when drug claims exceed sales. Module 3 covered steps 23 through 35 of the self-audit process. In module 4, we will review billing practices. Let's begin with the objectives for module 4. By the end of the "Module 4: Billing Practices" presentation, you should be able to: Identify three common reasons for billing errors; and Recall two types of inappropriate refill practices. Billing practices in the retail setting can be particularly confusing for pharmacy staff. This is especially true in high-volume situations where one is driven to perform data entry, process claims, and assemble and sell prescriptions with short turnaround times. The audit process is a means of reviewing pharmacy practices to ensure staff members uphold operational procedures. State and Federal programs such as Medicaid and Medicare Part D, State licensing boards, the U.S. Drug Enforcement Administration (DEA), the U.S. Internal Revenue Service (IRS), and other third party payers, conduct pharmacy audits. Through the pharmacy self-audit tool, pharmacy staff members can evaluate daily practices, pinpoint potential audit triggers, and proactively address vulnerabilities. Like any developing habit, a self-audit can become a part of daily, weekly, or monthly tasks. Pharmacists or their pharmacy managers can customize the pharmacy self-audit to ensure the self-audit addresses all pharmacy- specific compliance and operational procedures. When developing the blueprint for a customized pharmacy self-audit, consider the different forms of prescription drug fraud, waste, or abuse that may occur in the particular pharmacy setting and focus on these vulnerabilities. The self- audit process consists of 50 steps to help identify potential audit triggers in a pharmacy practice. The audit process includes detailed information regarding each step and is divided into four subsections that can be used separately or together as appropriate to meet the needs of the pharmacy practice: prescribing practices, controlled substances management, invoice management, and billing practices. Each subsection is addressed in the four modules of this presentation. The 50 steps described in the presentation modules correspond to the steps found on the "Pharmacy Auditing and Dispensing: The Self-Audit" checklist that accompanies this presentation. Consider each step, answer the questions listed, and examine existing policies and procedures to identify any audit triggers related to prescribing practices, controlled substances management, invoice management, and billing practices.Before beginning the "Module 4: Billing Practices" Self-audit. Gather the following information: Signature logs; "Pharmacy Auditing and Dispensing Job Aid: Billing Injectable Formulations"; "Pharmacy Auditing and Dispensing Job Aid: Billing Kits" "Pharmacy Auditing and Dispensing Job Aid: Billing Oral Formulations" and "Pharmacy Auditing and Dispensing Job Aid: Billing Other Dosage Forms." Let's take a closer look at the fourth component of the self-audit toolkit: the billing practices self-audit. A "stitch in time" is as true in the pharmacy business as any other setting. It requires more effort and time to correct an error than to do it right the first time. As errors are identified and rectified, talk with pharmacy staff about your findings, how to correct deficiencies, and what each staff member can do to prevent the error from recurring. Pharmacists and other pharmacy personnel represent a unique line of defense against fraud, waste, and abuse. Unnecessary costs to the Medicaid system are also overpayments to the pharmacy that, at a minimum, have to be repaid. Take a close look at billing practices, including billing units and calculations, refill practices, overrides, partial fill procedures, package size selection, and proof of delivery documentation. This module explains what to do next if the self- audit steps reveal potential overpayments. Reimbursements and rebates are two components of Medicaid prescription drug programs. When a pharmacy dispenses a prescription for a Medicaid patient, the State Medicaid agency (SMA) reimburses the pharmacy. Pharmaceutical manufacturers then provide statutorily defined rebates to the SMA for each unit of drug dispensed. SMAs reimburse pharmacies using the National Council for Prescription Drug Programs (NCPDP) Billing Unit Standard (BUS). Pharmaceutical manufacturers submit rebates to SMAs using the Centers for Medicare & Medicaid Services (CMS) unit of measure standards. Because SMAs must convert BUS units to CMS units, a pharmacy BUS claim submission error may result in inaccurate pharmaceutical manufacturer rebates to the SMA as well. It is critical that the pharmacy submit accurate information to the SMA for each drug dispensed. An incorrect National Drug Code (NDC) results in inaccurate rebates to the SMA. It is sometimes challenging to ensure patients receive the correct medication in the correct dosage form. The Pharmacy Self-Audit and Dispensing Toolkit includes job aids for drugs commonly associated with quantity or days' supply miscalculations. Provide staff with a copy when discussing these key concepts. You and your staff have a responsibility to ensure patients receive the correct medication in the correct dosage form. The health and safety of your patients are at risk if the pharmacy does not accurately dispense the prescription. It can also create liabilities for the pharmacy. An NCPDP pharmacist explains, "Billing unit errors can have serious consequences when state Medicaid agencies are involved, as underpayment or overpayment of rebates could generate a fraud investigation by the state or by the Centers for Medicare and Medicaid Services (CMS)." The NCPDP BUS helps pharmacists and staff members submit accurate claims for pharmaceutical products. NCPDP created the BUS to provide guidance to pharmacy claims software developers and to promote uniformity and consistency across standard billing units. The standards implemented by NCPDP address billing unit inconsistencies in the health care delivery industry that may result in incorrect reimbursement or difficulties defining what constitutes a billing unit. The standards provide a consistent and well-defined billing unit for use in pharmacy transactions, method to assign a standard billing unit, standard billing unit for use in the calculation of accurate reimbursement, and standard size unit of measure for drug utilization use and review. They also reduce the time it takes for a pharmacist to accurately bill a prescription and get paid correctly. The BUS employs only three billing units to describe any and all drug products. These billing units are milliliter, gram, and "each." Any product measured by liquid volume, such as injectable products of 1 milliliter or greater, reconstitutable non-injectable products at the final volume after reconstitution, and some inhalers, are billed as milliliter. Those measured by weight, such as creams or ointments in packages of 1 gram or greater, and some inhalers, are billed as grams. Tablets, capsules, suppositories, transdermal patches, non-filled syringes, tapes, blister packs, oral powder packets, powder-filled vials for injection, unit-of-use packages that contain less than 1 milliliter or gram, and kits are billed as "each." Calculating the correct days' supply can sometimes be confusing. The dose of a drug is the quantitative amount of drug for administration or consumption that produces the desired effect. However, days' supply calculations are not always easy or intuitive. Pharmacy staff members deal with kits, complex dosing regimens, and atypical dosing regimens. Arriving at the correct days' supply is as important as using the correct BUS when billing Medicaid. Again, the patient's health is the foremost consideration. An incorrect days' supply calculation can cause the patient to receive the wrong amount of medication, can cause claim rejections, or may raise audit red flags. Now, let's consider prescription requirements before discussing days' supply calculations. Prescription requirements for controlled and non-controlled prescriptions are similar. All prescriptions should include the date issued, the prescriber's signature and National Provider Identifier, drug name, strength, dosage form, quantity, directions for use, number of refills (if any), and the phrase "brand name medically necessary" if the prescriber elects not to allow generic substitution with a therapeutic equivalent. A prescription for a controlled substance must also include the patient's full name, address, practitioner's full name, address, and DEA registration number. Prescribers are required to write prescriptions for controlled substances in ink or pencil that cannot be erased and must manually sign the prescription on the date issued. Go over the prescription requirements with staff members. Your pharmacy is at risk if you don't comply with these requirements. In December 2014, an Oklahoma pharmacy was fined $43,000 in civil penalties for violation of the Controlled Substances Act (CSA). Between February 2010 and January 2014, the pharmacy improperly filled prescriptions for controlled substances that did not meet the prescriber's DEA registration number, substituted the prescriber's DEA registration number to fill prescriptions for controlled substances, and filled prescriptions for controlled substances under a non-valid DEA registration number. This is just one of many cases that involve violations of the CSA. There may be situations where staff can assist if presented with an incomplete prescription. Remind staff to contact the prescriber to obtain any information missing from the prescription blank if allowed by State and Federal regulations. But note that the DEA has strict requirements on this. On November 19, 2007, the DEA published a final rule in the Federal Register titled "Issuance of Multiple Prescriptions for Schedule II Controlled Substances." The DEA noted that the essential elements of the [Schedule II] prescription written by the practitioner such as the name of the controlled substance, strength, dosage form, and quantity prescribed may not be modified orally. Caution staff against adding the patient name, drug name, strength, dosage form, or quantity prescribed based on oral clarification for Schedule II prescription blanks that lack this information. Advise staff members to return the prescription blank to the patient so the patient can obtain a prescription that contains all of the legal requirements from the prescriber. Now, we will look at calculating the correct dispensing quantity and the correct days' supply. Sometimes the prescriber does not include the calculated quantity on the prescription blank. You are required to calculate the quantity by multiplying the number of doses per day by the required number of treatment days. Reverse- verify by dividing the given or calculated quantity by the number of doses per day to calculate the days' supply. The calculated days' supply may cause a claim rejection if the calculated value is over the plan maximum, typically between 30 and 34 days or between 90 and 102 days. The quantities and days' supplies on a prescription may not align. For example, a prescription written for 100 tablets for a 30 days' supply may also have a sig code stating the drug should be taken three times daily. You should either adjust the dispensed quantity to 90 tablets for 30 days or adjust the days' supply to 33. Staff members need to understand the importance of the days' supply accuracy. The pharmacy will be financially liable if they incorrectly adjust the days' supply in this instance to 30 days while dispensing 100 tablets. Improperly adjusting the days' supply may lead to negative audit findings. Most payers will prevent the pharmacy from dispensing any quantity of a prescription drug over time that exceeds the maximum recommended under U.S. Food and Drug Administration (FDA)-labeling of the drug in question. However, you should not rely on those measures to keep your pharmacy from over-issuing that drug. It is ultimately your responsibility to not exceed such quantity limits. Your pharmacy will be held financially liable if you fail to prevent this. You will also be presented with prescriptions for doses that, while unusually high, do not exceed the FDA threshold. Consult a drug reference if a prescribed dose appears excessive to determine if the dose prescribed is within FDA- labeled guidelines. The National Library of Medicine provides a free drug reference, DailyMed, found on the first website listed here. Simply enter the name of the drug, navigate to the drug in question, and consider the dosage and administration guidelines listed in the product label. In addition, the FDA has a repository of all marketed brand name product labels, accessible on their website. You should also verify the dose with the prescriber if you confirm the amount prescribed exceeds FDA-labeled recommendations. Document the verification on the hard copy. Include the diagnosis and the reason for override on the hard copy, if available. You need explicit directions to accurately calculate the days' supply for prescriptions requiring more than one billing unit per month. This is particularly important for these types of medications: Shampoos--Document frequency of use and size of area to be treated; Creams and ointments--Document frequency of use and size of area to be treated Migraine medications--Document number of headaches treated per month Insulin--Document exact regular dosage and maximum daily dosage for any sliding scale directions; and Diabetic syringes, test strips, or lancets. Document maximum use per day. Next up, inappropriate refill practices by pharmacies. Pharmacy staff performance incentives have been linked to common, and heavily promoted, refill practices. For example, "push billing" causes prescriptions to be auto-refilled without the patient's request or consent. This is illegal for Medicaid prescriptions. Participating pharmacies claim these programs improve clinical outcomes through improved patient adherence to therapy regimens. However, these programs are rife with potential fraud, waste, or abuse, particularly when the auto-refill prescriptions are subsequently mailed to the patient upon completion. Internal requirements may pressure pharmacists to enroll patients in auto- refill programs. That was the case with a large chain investigated by the Department of Justice's (DOJ) Civil Fraud Division. The DOJ investigated auto-refill practices and alleged the chain auto- refilled and billed prescriptions without patient consent, while pressuring pharmacists to meet 40 percent auto-refill enrollment goals. Do not auto-refill for Medicaid patients without a request from the patient. Obtain consent prior to delivery of each refill if State law allows and the patient has enrolled in an auto-refill program. Only contact a patient to solicit requests for medication refills if a pharmacist has assessed the prescription history and the outreach is an attempt to improve the patient's medication adherence and clinical outcome. Pharmacies also employ marketing tactics that can inappropriately affect patient choice. Financial incentives may include shopper loyalty programs that provide cents off gallons of gas or store credit, gift cards, or merchandise. You are prohibited from using financial incentives to influence a patient's choice of pharmacy services for prescriptions paid by Federal health care programs. "Pharmacies are not allowed to improperly influence the decision- making of Medicare and Medicaid patients about where to fill prescriptions," said Special Agent in Charge Glenn R. Ferry for the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) "Pharmacy chains that manipulate patient choices in this way will be held accountable." In addition, pharmacies should not waive copayments as an incentive to refill unneeded prescriptions. However, States require a pharmacy to fill and dispense a Medicaid prescription, even if the patient cannot pay the copayment or refuses to pay the copayment. Pharmacies are not the only ones that may drive inappropriate refill practices. You need to routinely evaluate the risk of patient stockpiling or diversion. Medication stockpiling is the excessive and inappropriate accumulation of prescription or nonprescription medications for later use. There are a number of reasons for stockpiling. They include: fear of product shortages and terrorist attacks, impending loss or change of drug benefit coverage to a plan with higher co-payments or different formularies, and intentional or unintentional drug abuse. Stockpiling medications is an expensive, unnecessary, wasteful, and potentially dangerous circumvention of appropriate health care resources. Be alert to potential harm to patients, depending on the medication, and be cognizant of warning signs patients may exhibit at the point of sale. Counsel patients you suspect are stockpiling. Drug diversion is best defined as the redistribution of licit drugs for illicit purposes. It involves the diversion of drugs from legal and medically necessary uses toward uses that are illegal and typically not medically authorized or necessary. While drug diversion is not a new phenomenon, States are reporting a significant increase in the problem. The impact of drug diversion on the Medicaid program goes beyond just the cost of the prescription drugs. There are also the costs associated with doctors' visits, emergency department treatment, rehabilitation centers, and other health care needs. Part of the pharmacist's corresponding responsibility includes being alert to suspicious behavior on the part of the person presenting the prescription. The California State Board of Pharmacy recommends that a pharmacist must also rely on his or her professional judgment to discern when a prescription seems suspicious. The board offers indicators pharmacists can use, including, but not limited to irregularities on the face of the prescription, demeanor of the patient, requests for early refills, and initial prescriptions written for strong opiates. Be aware of other red flags that may indicate diversion and require further scrutiny. The patient requests to pay cash when insurance coverage exists; One patient drops off or picks up multiple similar prescriptions for two or more patients; Similar or identical prescriptions originate from the same prescriber or practice for inordinately large quantities of medications typically diverted; Groups of patients drop off similar or identical prescriptions for commonly diverted medications, often written by a prescriber who practices in another city, county or State; The patient is unable to provide identification when requested; The diagnosis given by the patient does not match the diagnosis given by the prescriber; The prescriber is unable or unwilling to give a diagnosis or provides the same diagnosis for all patients, such as back pain or degenerative disc disease; The prescriber is unavailable to speak directly with the pharmacist, will not return calls, or takes an unusual amount of time to respond to the pharmacist. The prescriber has not committed his or her DEA registration number to memory The prescription does not contain all federally mandated information; or The prescription does not comply with tamper-resistance industry standards or appears tampered with. Report your concerns to the proper authorities if diversion is suspected. You and your pharmacy are liable for your failure to exercise corresponding responsibility by filling a prescription you knew or should have known to be illegitimate. It can have costly consequences. In June 2013, one of the nation's largest chain drug stores agreed to an $80 million settlement amid allegations that its pharmacists knew or should have known customers filling oxycodone prescriptions at several Florida locations would divert these drugs into the black market for illegal sale and abuse by the final user. Report suspicions by notifying one of these agencies: Local law enforcement; U.S. DEA; State Medicaid Fraud Control Unit; and State licensing board if a health care professional is involved. Or contact: U.S. Department of Health and Human Services, Office of Inspector General. Familiarize pharmacy staff members with ways that patients commonly divert prescription drugs, including: card sharing, medication sharing, prescription pad theft, forged or altered prescriptions, doctor shopping, and theft. Inappropriate use of overrides. Payers, including Medicaid, will suspect fraud, waste, and abuse if you inappropriately use override codes to facilitate prescription processing. Your best defense against such suspicion is to accurately and completely document the justification for their use. Staff members should never use prior authorization (PA) codes if the patient does not meet the PA criteria. Likewise, never use vacation supply override codes if the patient is not on vacation. You and your pharmacy risk overpayments and other sanctions for improperly overriding system edits. In a recent example of a "worst case scenario," a New York pharmacy completely falsified PA information to process claims for Medicaid and Medicare patients. The specialty pharmacy agreed to pay $9.5 million in fees to the Federal government and roughly $450,000 to the State of New York. Pharmacy employees pretended to be with the prescriber's office and used their knowledge of PA criteria to provide clinical information to insurance representatives so the patient appeared to meet the necessary requirements for medication coverage. Although origin and dispense as written (DAW) code selection may be a relatively simple task, these two areas are vulnerable to pitfalls. A prescription origin code identifies the method by which a pharmacy receives a prescription. It is important to note that any changes made to the original prescription do not change the origin code. Prescriptions received via telephone (origin code 2) may be particularly vulnerable to risk. You should always include the physician's proper callback number. In a case involving the New York Medicaid program, an initial audit sample of 172 phone-in prescriptions, 69 were found to be improper. Verify the prescriber DEA number and office telephone number for all controlled substances prescriptions received via telephone. If you do not know the caller, or are unfamiliar with the prescriber, take the time to confirm the contact information with a secondary source. If the contact information differs, call the prescriber's office via a published telephone number to confirm the prescription. This table indicates the origin code values and their appropriate use. "Dispense as written" or DAW codes on the next two slides are known as the DAW designation. The DAW describes the reason a particular brand is dispensed based upon direction from the prescriber. Red flags will be raised in audits identifying the excessive use of certain DAW codes, especially the use of DAW 1 on multi-source products. Review acceptable use of all DAW codes. Staff should be alert to the appropriate use of DAW 1 and DAW 2 codes, in particular. Select DAW 1 only when the prescriber indicates product selection is not allowed. Select DAW 2 only when the patient chooses to receive the brand name product over the generic. Emphasize appropriate documentation procedures. Proper documentation on prescriptions, especially those received via phone, is critical to withstand audit scrutiny and avoid accusations of modifying the prescription to increase revenue. The phrases "brand medically necessary" or DAW are needed in the cases of DAW prescriptions. DAW codes five through nine are listed here. Sometimes, State Medicaid plans may request a brand instead of a generic substitution In these instances, with proper documentation, DAW 9 is appropriate. Partial refills represent another practice associated with fraud, waste, or abuse and are discussed next. A partial fill occurs when a pharmacy bills for the entire prescribed quantity, but dispenses only a partial supply while waiting for delivery of additional stock. Only bill for the amount dispensed. You should not bill a second dispensing fee when you do complete the prescription. It is very easy for pharmacies, even with good intentions, to be overpaid for partial fills. The patient may not pick up the owed portion, or the pharmacy may not be able to obtain additional supply of the medication. The pharmacy may also bill the completion of the partial fill as a refill. If the medication is returned to stock, the pharmacy inventory is inaccurate, and Medicaid has overpaid the pharmacy. The excessive use of partial refills is a red flag for your audit. In a recent New York Post article, a Veterans Administration (VA) nurse alleged potentially risky practices at an Albany hospital when she described pharmacy practices that included complete prescription processing without any drug available to fill the vial. She alleged veterans were given an empty pharmacy bag with the prescription information and an "IOU" stapled to the bag. An OIG investigation related to $25 million in overpayments by Medicare Part D for Schedule II prescriptions identified partial fill completions billed as refills. Implement a sound partial-fill protocol, including proper documentation, to avoid accusations of partially filling prescriptions in an effort to generate dispensing fee revenue. Billing errors may commonly occur with regard to package size selection. Most notably, topical preparations, reconstituted products, and compounds are at greatest risk. Advise staff to normally select the smallest commercially available package size. However, sometimes it is not practical to select the smallest size. For example, a topical preparation may be needed for a large affected area. Always document the rationale for choosing the larger size. Discuss the importance of this documentation with staff. Staff must ensure the NDC dispensed matches the NDC billed. Billing practices related to compound medications may also cause confusion. Payers may suspect fraud, waste, or abuse if a staff member bills for the entire contents of a package to create a compound when a smaller volume would have been adequate to create the compound. Do not flag non-compounded medications as compounds. A pharmacy owner in West Virginia recently pleaded guilty to defrauding Medicare and Medicaid for dispensing compounded generic medications and billing for the brand. Medicare and West Virginia Medicaid will recover $1.1 million from a settlement with the pharmacy. Prevent overpayments and pharmacy liability by reviewing compound prescription billing procedures with staff to ensure the correct package size and NDC are selected and billed appropriately. It can be difficult to appropriately bill for compounded medications. Like any other issue, improper billing will lead to extensive auditing. By their nature, compounded medications are already a bit of low hanging audit fruit, given that every prescription submitted as a compound has a flag. Pharmacy staff must ensure that the need met by using the compounded medication is not possible with any commercially available product and the treatment is medically necessary. States' coverage for compounded medications may vary with regard to coverage requirements, excluded ingredients, and prior authorization. Therefore, it is imperative that pharmacy staff are aware of the billing requirements for Medicaid plans to which the pharmacy bills. States may require prior authorization for a compounded medication with a reimbursement above a particular dollar amount. Nebraska Medicaid, for example, requires prior authorization for compounded prescription claims above $140. Products requiring reconstitution or the addition of flavoring syrup to products are not compounded medications. In general, claims are required to list all of the NDCs for medications in the compound, each ingredient used in the compound, and accurate quantities for each ingredient. Inclusion of accurate quantities must be a priority. The New York Attorney General recently announced a $100,000 settlement with a pharmacy for billing inaccurate amounts of ketamine. While no evidence exists that the use of the compounded medications was illegal, pharmacy staff billed ketamine as the entire weight of the compound instead of for the amount actually used. Obtain the signature of everyone picking up prescriptions. Failure to maintain signature logs puts you and your pharmacy at audit risk. Payers will suspect fraud if you do not have records to demonstrate proof of delivery. Pharmacies have been known to use identity theft as a means to bill for false prescriptions. Be alert to absent or forged signatures when routinely examining signature logs. You can prevent or earlier detect overpayments by having appropriate protocols in place for the areas previously discussed. If an overpayment to Medicaid is identified and the claim was paid within the last year, simply reverse the claim. In cases of older claims, submit a check with an explanation to your SMA. The OIG and many States have provider self-disclosure protocols that you should use to report inappropriate payments. The OIG explains that self-disclosure affords the payee an opportunity to proactively identify the inappropriate payment from an HHS program in an effort to lessen the impact of penalties and inquiry when the inappropriate payment is not self-discovered. Information on how to perform self-disclosure may be found on the OIG website. One of the worst things a pharmacy can do is be aware of overpayments but fail to return them, even if you take steps to prevent them in the future. You have an affirmative obligation to bill appropriately in the first place and return all overpayments that do occur. Pharmacies must report the overpayment within 60 days from the date the overpayment is identified. Overpayments usually include the following situations: At the time of the service, the individual receiving the service was not eligible for Medicare or Medicaid; Medicare or Medicaid mistakenly paid as primary where another third-party payer was primary unless the state has a mandatory pay and chase provision. The payment amount was miscalculated and excessive; The service did not fall within one of the statutory benefits or was subject to a statutory exclusion; or The service was not medically necessary. Your pharmacy is financially liable for any overpayments, no matter the cause or lack of intent to overbill. But if the pharmacy or pharmacist intended to overbill, the risk is much greater. The Federal False Claims Act (FCA) allows "whistleblowers" to collect part of any monies recovered in an FCA action against a provider. The FCA includes a treble damages provision, a tripling of actual and compensatory damage, for persons who have "actual knowledge, deliberate ignorance of the truth or falsity of the information, or reckless disregard of the truth or falsity of the information." In addition, persons may be found to have violated the FCA in reverse--not by receiving money to which the person is not entitled, but by avoiding payment of monies due the Federal government. Many States also have their own FCA. Finally, a pharmacy may be terminated as a Medicaid provider for cause because the pharmacy has engaged in any number of inappropriate activities, including improper billing, even if there was no intent to defraud the payers. Identifying and reporting overpayments in a timely manner will prevent negative consequences and offers the pharmacy the opportunity to provide staff training to prevent future overpayments. We conclude module 4 with two knowledge checks. This knowledge check asks you to match a prescription to a type of billing error that may occur. The prescription examples are: 1._____Atorvastatin 10mg Sig: 1 tab tid #30 2._____Amox/clav 200 Sig: 1 tsp bid x7d 3._____Nifedipine 10mg Sig: One capsule tid #100 for 30 days 4._____Fluticasone 0.05% cream Sig: UAD And the four billing errors that may occur: A. Unusual prescribed quantity may cause days' supply-related billing error B. Multiple package sizes may contribute to billing errors C. Unlikely to cause error because days' supply and quantity match. D. Undefined package size and day Match the prescription to the type of billing error that may occur: Correct Answers: Number one: C: Unlikely to cause error because days' supply and quantity match Number two: B: Multiple package sizes may contribute to billing errors Number three: A: Unusual prescribed quantity may cause days' supply-related billing error Number four: D: Undefined package size and day Which of the following refill practices listed are not appropriate? Select the best option. A. A patient with Tricare refills a prescription and is given a $10 store credit. B. A patient with Medicaid is enrolled in an auto-refill program without consent or request. C. A regular patient has been refilling her prescriptions about a week early every month. She has requested vacation overrides several times, expresses her fear regarding an electromagnetic pulse attack, and confides to you she is trying to accumulate as many medications as possible "just in case." You dispense today's refills and help her get overrides for unnecessary vacation supplies. D. All of the above. Correct Answer: D: All of the above CMS is committed to educating pharmacy providers about potential fraud, waste, and abuse related to pharmacy services. Modules 1 through 4 give more information about the 50-step self-audit process outlined in the accompanying booklets and checklist included in this toolkit. The self-audit analysis process is broken down into four key areas Prescribing practices; Controlled substances management, Invoice management, and Billing practices. In addition, the presentation modules help participants identify areas prone to potential fraud, waste, and abuse in the pharmacy related to pharmacy services. They also provide instruction on how to report them. Participants can use audit findings to identify areas of practice that require further scrutiny and can use these tools to educate pharmacy personnel about potential fraud, waste, and abuse. This presentation was current at the time it was published or uploaded onto the web. Medicaid and Medicare policies change frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. Use of this material is voluntary. Inclusion of a link does not constitute CMS endorsement of the material. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.