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Greetings,

We are seeing an increased instance of medications billed for an incorrect day supply “to get it to go through”. 
 
Medications must be billed for a correct day supply according to the prescription written.  Medicaid may reject a prescription that either is a subtherapeutic dose based on the quantity per day supply billed or requires prior authorization (in the case of Toujeo and Tresiba) for the prescribed dose. In either case, if a medication rejects for invalid day supply, the prescription should either be clinically evaluated and clarified with the prescriber for an appropriate therapeutic dose, or submitted for a prior authorization.
 
Intentionally billing with an incorrect day supply to get a claim to pay is a type of Medicaid fraud and will be recouped on audit. Medicaid fraud is defined as the intentional providing of false information to get Medicaid to pay for medical care or services.  If we discover it, the claims will have to be reversed, even if the prescription is already dispensed or we have to report it to our program integrity unit and the money paid will be recouped.

Please work with your staff to avoid this practice. We do not want to have to take back money, especially as some of these are very expensive medications.
 
Examples of what we have been seeing recently:
 
Victoza 0.6mg/day prescription is filled by billing a 1.2mg/day (2-pack) filled for qty 9/30 day supply and is rebilled every 60 days
  • We have implemented an underutilization edit on Victoza to prevent a rebill of this practice
  • Victoza 0.6mg/day is a subtherapeutic dose and the prescriber should be contacted to correct the dose to a therapeutic range.
Pulmicort 360mg twice daily prescription is filled with 90 mcg/1 actuation inhaler for 30 days and an override is requested 15 days later when claim rejects for refill to soon
  • The higher dose inhaler 180mcg/1 actuation has the proper quantity limits to reach this dose with a 30 day supply
Tresiba 200 units/mL prescription for 30 units/day is filled by billing a 9 mL package for 30 days supply and rebilled every 60 days
  • We have adjusted the quantity limit edit for Tresiba U-200 to prevent this billing practice
  • Tresiba U-200 does not require prior authorization approval for coverage of doses between 100-200 units/day
  • Tresiba U-200 requires prior authorization with the same criteria as Tresiba U-100 for doses below 100 units/day, so the prescriber will need to be contacted to switch to a preferred product or submit a prior authorization request
Alexi Murphy, PharmD
Quality and Operations Pharmacist, Pharmacy Services
 
701.328.4061   •   701.328.1544 (fax)   •   711 (TTY)   •  amurphy@nd.gov •   DHS Home Page


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