As healthcare providers, pharmacists and pharmacies are always eager to work with patients to provide care in a timely manner, while contending with various types of insurance limitations and restrictions. One common type of insurance restriction facing pharmacies is the concept of plan quantity limitations, which occurs when a patient’s prescription drug plan will only cover up to a certain amount of a given medication at a given time, regardless of what has been prescribed by the patient’s physician.
When a prescription is authorized for a larger quantity than is covered by insurance, pharmacies may seek to dispense a reduced quantity (i.e., short-fill) that the insurance plan will cover. However, pharmacies in Pennsylvania are increasingly finding themselves on the losing end of Medicaid audits, facing significant chargebacks for claims submitted to Medicaid Managed Care Organizations (MCOs) after dispensing prescriptions for smaller quantities than originally authorized in order to meet plan limitations without obtaining and documenting a prescriber’s consent to do so.
This occurs despite the fact that relevant Pennsylvania pharmacy regulations, specifically 49 Pa. Code 27.18(b)(3), explicitly permit a pharmacist to dispense a different quantity than what is written on a prescription, so long as such changes are properly noted on the original prescription and in the pharmacy’s records. Even so, Pennsylvania’s Department of Human Services (DHS) has pointed to other sections of state law to justify the recoupment of amounts paid for prescriptions, which were otherwise validly dispensed.
This recent trend is yet another example of audit standards being at odds with common pharmacy practices. Nevertheless, Pennsylvania pharmacies should be sure to consult with the prescriber before reducing the quantity of a prescription for a patient in a Medicaid MCO plan, and more importantly, document that interaction to confirm the prescriber’s consent in the event of an audit. Per the Pennsylvania laws cited by DHS[1], pharmacies should also ensure that any such changes, as well as the pharmacist’s reasons for making them, are recorded on the original prescription.
How Frier Levitt Can Help
If your Pennsylvania pharmacy recently received adverse audit findings from the DHS, is in the process of responding to an audit, Frier Levitt can help. Contact us today to speak with an attorney.
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[1] 55 Pa. Code 1121.52(c)
