FROM: PAM MASON, Acting Bureau Chief
Medicaid Programs and Resource Management
The Medicaid Fraud and Surveillance and Utilization Review Units have recently audited several pharmacies enrolled as Medicaid providers and identified areas of concern regarding the maintenance of documentation to support services billed to the Medicaid program. These audits consisted of reviewing records at facilities who classify themselves as either retail or closed door pharmacies. Record keeping and other prescription requirements are the same regardless of the status of the pharmacy as a retail pharmacy or a closed door pharmacy servicing residents of care facilities. As a result of these audits, the Department is issuing this information release to clarify record keeping and program requirements for all pharmacy providers when dispensing prescriptions to Medicaid clients.
The audits identified occurrences where providers failed to maintain documentation of prescriptions billed to the Medicaid program or the records were maintained in such a manner which did not allow for immediate review. Idaho Code §56-209h(2) requires providers to generate documentation at the time of service sufficient to support each claim and retain the documentation for a period of five (5) years from the date the item or service was provided. The Department shall be given immediate access to such documentation upon written request. Prescriptions shall be maintained on file in pharmacies in such a manner that they are available for immediate review upon request.
Prescriptions and Prescription Refills:
The audits identified numerous insufficient records documenting prescription refills billed to the Medicaid program. All prescriptions and prescription refills must be dispensed in accordance with the Rules Governing Medical Assistance and the Rules and Regulations of the Board of Pharmacy.
All prescriptions must be ordered by a licensed practitioner, and the original prescription order
must be maintained in the pharmacy files. This documentation must also include the number of refills authorized to be dispensed.
The audits identified pharmacies who have dispensed refills in an amount greater than the amount authorized on the original prescription order in the pharmacy files. Pharmacy computers serving as alternate record keeping systems were then utilized to record the change of the allowed refills to an amount greater than allowed on the original order on file. A computer, or alternate record keeping
system, is for recording and tracking refills dispensed and may only be used in the pharmacy with the original prescription order on file. All prescription orders that are legally refillable must have the refill instructions indicated on the face of the original prescription order. If an order is changed, whether it is the drug quantity, the directions for use, or additional refills it becomes a new prescription and the documentation maintained must reflect this as a new order.
All original prescription orders in the pharmacy files must document, at a minimum, the name of the patient; the date written; the directions for use; the name, strength and amount of medication; the name of the prescriber; and if written, the pre-printed, stamped or hand printed name of the prescriber and the hand written signature of the prescriber. No prescription is refillable unless specifically indicated by the prescriber.
Billing For Services Not Rendered:
The audits of various pharmacies have revealed instances where Medicaid was billed for prescriptions dispensed, however, the prescriptions were placed on hold or were not actually picked up by the Medicaid client. In addition, it has also been identified where pharmacies have billed Medicaid for dispensing medications to clients residing in long term care facilities, several days to several weeks after the client’s date of death. Providers will be expected to communicate with the long term care facilities information regarding the status of each resident to ensure the resident is in the facility and requiring additional medications. The Department reviews claims for services reimbursed on dates after the recorded patient=s expiration date and recoups any claims paid inappropriately.
Multiple Dispensing Fees/34 Day Supply:
The audits identified instances where pharmacies billed Medicaid for multiple dispensing fees for the same prescription, in one calendar month. Only one dispensing fee will be allowed for the dispensing of each maintenance drug to any client as an outpatient or a resident in a care facility, except as specifically allowed by rule. In addition, no more than a thirty-four (34) day supply of continuously required medication will be reimbursed by Medicaid in a calendar month as a result of a single prescription, except as allowed by rule.
Prescriber’s State License Number:
All pharmacy claims must contain the prescriber=s state license number issued by their licensing board. The number must be entered in the prescriber code field on the claim. If the prescriber is not licensed within the State of Idaho, enter 777777 in the prescriber code field and check the O/S (Out of State) field. The Department has identified where pharmacies have submitted claims with a physician=s DEA number or used 777777 when the physician was licensed in Idaho and had an Idaho license number. Billing in this manner will be considered an improper claim and subject to recoupment.
The Medicaid Fraud and SUR Units will be following up to further review pharmacies for compliance with record keeping and program requirements. Violations of the pharmacy regulations will be referred to the Board of Pharmacy.
If you have any questions regarding this information, please contact Gary Duerr, R.Ph., at (208) 364-1829.
Thank you for your continued participation in the Idaho Medicaid Program.