Pharmacy Practices to Improve Medicaid Program Integrity & Quality – Module 1 Prescribing Practices


Welcome to the Pharmacy Self-Auditing: Control Practices to Improve Medicaid Program Integrity and Quality – Module 1: Prescribing Practices presentation. Pharmacies are subject to auditing from many agencies, including your State Medicaid agency (SMA), the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), Federal and State contractors, State pharmacy licensing authorities, the U.S. Drug Enforcement Administration (DEA) and third-party payers. Knowing what to expect and how to prevent deficiencies helps prevent fraud, waste, and abuse in your pharmacy. Let’s take a moment to consider how rising pharmaceutical costs have increased the need for payers to audit pharmacies. Pharmaceutical expenditures in the United States were just over $1,000 per capita in 2012, which is 11.5 percent of total health care expenditures $8,745 per capita. Total health care expenditures represented 8 percent of the gross domestic product. As a result, payers of pharmaceutical claims have a vested interest in validating claims as appropriate The audit process allows payers to identify unusual or excessive pharmaceutical claims and ensure pharmacy compliance with contractual obligations. Let’s look at the cost of Medicaid on the next slide. The Affordable Care Act of 2010 expanded Medicaid eligibility in States that have adopted Medicaid expansion. In such States, Americans who earn less than 138 percent of the Federal poverty level, $33,465 for a family of four in 2015 are eligible to enroll in Medicaid. The National Health Expenditure Projections Forecast for 2014-2024 estimates Medicaid spending will grow by 5.9 percent on average annually from 2015 through 2024. According to the Kaiser Family Foundation, the Medicaid program paid for 520 million prescription claims and spent $20.6 billion in total drug utilization expenditures in 2012 after recouping rebates. The sheer volume of claims and expenditures requires Medicaid to protect itself from fraud, waste, and abuse. Pharmacy providers can identify areas of practice that require further scrutiny and can use these tools to help educate staff about potential fraud, waste, and abuse. It is helpful to know how fraud, waste, and abuse are defined. Title 18 of the United States Code defines health care fraud as knowingly and willfully executing, or attempting to execute, a scheme to defraud a health care program or obtain money or property from a health care program under false pretenses. Medicaid fraud artists intentionally submit false claims or misrepresent facts to obtain funds to which they are not entitled. Federal Medicaid regulations do not define waste, but it is not usually associated with criminal actions. Think of waste as overutilization or misuse of services. Abuse may encompass waste and includes any action that may cost the Medicaid system unnecessary dollars. Abuse may include improper payment for services payment for services that fail to meet professionally recognized standards of care, or payment for services that are not medically necessary Abuse includes reimbursement for claims to which the provider is not entitled, but health care professionals guilty of abuse do not intentionally misrepresent facts to obtain payment. Like waste, abuse is not usually associated with criminal actions. Estimates of dollars lost to public and private insurers from health care fraud are in the tens of billions of dollars annually. Let’s examine your role as a pharmacy manager pharmacist-in-charge, pharmacist, pharmacy technician, or other position in support of pharmacy services in efforts to reduce fraud waste, and abuse. Pharmacy personnel have a unique role in the health care system that often allows intervention before fraud, waste, or abuse occurs. Due to the high risk for improper payments, CMS developed the Pharmacy Self-Auditing: Control Practices to Improve Medicaid Program Integrity and Quality Toolkit to educate pharmacy providers on self-audit precautions related to proper prescribing practices, controlled substances management invoice management, and proper billing practices. In addition, the toolkit addresses potential fraud waste, and abuse related to pharmacy services and how to report them. Let’s review the objective of this presentation. By the end of the Module 1: Prescribing Practices presentation, the learner should be able to recall five types of off-label uses a prescribing practice self-audit would help identify. Unidentified fraud, waste, or abuse puts pharmacies at risk. The pharmacy’s reputation and its ability to conduct business are threatened when the pharmacy does not pay close attention to its practices. What are the financial risks of false claims? The Federal False Claims Act (FCA) punishes past fraud and, hopefully, deters future misbehavior, by imposing civil liability on persons who knowingly submit a false or fraudulent claim or engage in various types of misconduct involving Federal government money or property. From January 2009 through the end of the 2013 fiscal year, the Justice Department used the FCA to recover more than $12.1 billion in health care fraud. A 2012 OIG report identified 2,637 retail pharmacies with questionable billing practices. The investigation found that suspect pharmacies billed high dollar amounts per patient, billed a high number of prescriptions per patient, or billed for a high number of prescriptions per physician prescriber. As a result, OIG recommendeds that CMS strengthen oversight of pharmacies and pharmacy audits. Pharmacists and other pharmacy personnel who self-monitor practices within the pharmacy prevent, identify, and correct potential fraud waste, or abuse. Let’s take a look at the self-audit process on the next two slides. 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 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. Let’s take a closer look at the first component of the self-audit toolkit. The prescribing practices self-audit. How can a pharmacist or someone who supports pharmacy services help combat the inappropriate and costly prescribing of certain medications? By performing a prescribing practice self-audit. A prescribing practice self-audit helps identify prescriptions written by providers who appear on the OIG List of Excluded Individuals/Entities (LEIE), prescriptions written outside the prescriber’s scope of practice, and prescriptions written for off-label indications. By knowing what to look for, prospective review can be performed on a continuous basis. In addition, when you implement these self-audit practices, you not only improve patient care and safety, but also help protect the State Medicaid program. You should also check all pharmacy owners agents, managing employees and staff through the LEIE database on a monthly basis. Billing for items or services provided by excluded persons puts the pharmacy as risk. Let’s take a look at the LEIE data base. It is important to note that Federal health care programs cannot pay for items or services furnished by an excluded provider or entity or for a prescription drug claim based on a prescription written by an excluded physician as stated in sub section 1862(e)(1)(B) of the Social Security Act and in 42 C.F.R. subsection 1001.1901. Medicare, Medicaid, and any other Federal health care program will withhold reimbursement if: A medication is dispensed that was written by a prescriber currently excluded from participating in Medicare, Medicaid, or any other Federal health care program. An excluded pharmacist inputs prescription information for pharmacy billing. An excluded pharmacist is involved in any way in filling prescriptions for drugs that are billed to a Federal health care program; or Administrative or management services payable by a Federal health care program are provided by an excluded individual or entity. To check the status of a provider or staff member visit the HHS-OIG website. You can also download the LEIE and subsequent monthly updates to set up regular checks of frequent prescribers and pharmacy staff. An excluded person that submits a claim for payment to a Federal health care program, or causes such a claim to be submitted, may be subject to a civil monetary penalty of $10,000 for each claimed item or service furnished during the period that the person was excluded. The person may also be subject to an assessment of up to three times the amount claimed for each item or service. In addition, violation of any exclusion is grounds for OIG to deny reinstatement to Federal health care programs. In January 2015, a Minnesota pharmacist entered into a $96,259.57 settlement agreement with OIG for HHS. The settlement resolves allegations that from March 10, 2006, to July 17, 2013, the pharmacist owned and managed a pharmacy that participated in Federal health care programs while the pharmacist was excluded from participating in these programs. In addition to identifying excluded providers, it is important to determine if prescriptions presented for fill meet all legal requirements What constitutes a legitimate medical purpose? As the gatekeepers to medication access pharmacists must exercise corresponding responsibility to determine if each controlled substance prescription was issued to a patient for a legitimate medical purpose by an authorized prescriber acting in the usual course of professional practice or if the situation may require further investigation. It is a violation of the Controlled Substance Act (CSA) to fail to fulfill that corresponding responsibility. Pharmacists who fail to comply may be held liable for their actions. To help prevent fraud, waste, and abuse, SMAs can hold non-controlled prescriptions to the same standard. The Social Security Act permits States to provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan, as may be necessary to safeguard against unnecessary utilization of such care and services. In 42 C.F.R. section 440.230(d), CMS says SMAs may place appropriate limits on a service based on such criteria as medical necessity You should also understand the prescriber’s scope of practice when filling a prescription. States place professional and positional limits on the scope of some prescribers’ practices. A prescriber should only write and a pharmacist should only dispense prescriptions that fall within the scope of practice of the prescriber. Each State defines scope of practice limitations that apply to a particular health care profession. Some States allow nurse practitioners and physician assistants to prescribe CSA Schedule II narcotics, while other States reserve this prescribing privilege for physicians. Consider the prescriber’s State scope of practice limitations before filling prescriptions. Pharmacists also have a responsibility to question prescriptions from prescribers with a variable scope of practice. For example, it would be outside the scope of practice for an optometrist to write a prescription for birth control pills, but within the scope of practice for ophthalmic or oral antibiotics. Some scope of practice situations may require careful consideration. For example, a dentist may prescribe narcotic medications to treat dental pain, and to do so is within the dentist’s scope of practice when prescribed to treat acute pain. However, you should question a prescription written by a dentist for OxyContin (oxycodone extended release) for app ropriate scope of practice because OxyContin is approved only for chronic pain. In 2012, the Kansas Dental Board admonished a Wichita dentist for prescribing oxycodone- containing or propoxyphene-containing controlled substance prescriptions to patients for the treatment of medical, rather than dental, conditions. These actions violated the Kansas Statutes Annotated 65-1436(a)(10) and as a result, the Kansas Dental Board restricted the dentist’s license by prohibiting her from writing prescriptions for any controlled substance. Prescribers should write prescriptions with the intent to treat Food and Drug Administration (FDA)-labeled or compendial indications to meet the requirements of a legitimate medical purpose for payment purposes. But what does that mean? What is the pharmacist’s role in the process? Here we define labeled, compendial, and off-label use. Labeled indications are those approved by the FDA for each drug. It is common, however, for a prescriber to prescribe drugs for indications other than those shown in the label information. Compendial prescribing is outside FDA-approved use but can be found in an approved compendial source. Off-label prescribing occurs when the prescriber writes a prescription for a drug to treat an indication that is neither FDA-approved nor found in approved compendial sources Approved compendial sources can vary by State, but may include the American Hospital Formulary Service (AHFS) Drug Information, Thomson Micromedex DrugDex Information System, the National Comprehensive Cancer Network Drugs and Biologics Compendium (NCCN Compendium), or Elsevier Gold Standard’s Clinical Pharmacology The classes of drugs frequently associated with inappropriate prescribing practices and the ones this presentation focuses on are: transmucosal immediate-release fentanyl (TIRF) products, buprenorphine-naloxone products for opioid dependence, atypical antipsychotics, phosphodiesterase inhibitors (PDEIs), topical retinoids, in jectable botulinum toxins, incretin mimetics, amphetamines, and cannabinoids. Let’s begin with a look at the potential inappropriate prescribing of TIRF drugs. TIRF medicines are subject to misuse and abuse. They contain fentanyl, an opioid agonist and a Schedule II controlled substance. These products are indicated only for managing breakthrough pain in adult cancer patients who are already receiving and who are tolerant to around- the-clock opioid therapy for their underlying persistent cancer pain. Prescribers and pharmacists must first be enrolled in the TIRF Risk Evaluation and Mitigation Strategy (REMS) program before the pharmacy’s claim management system adjudicates the claim for a TIRF medication. Regardless of the type of medication being prescribed, when a customer presents with
an off- label prescription, the Indian Health Service (IHS) counseling technique is a helpful tool for counseling patients and is particularly useful when considering drug classes commonly written for off-label uses. Ask the patient the following questions: What did your prescriber tell you the medication is for? How did your prescriber tell you to take the medication? What did your prescriber tell you to expect? This interaction helps verify the patient or caregiver understands the medication that he or she is being prescribed and should be used to verify the intended indication for medications commonly associated with off-label use. If, during counseling for a TIRF medication you discover the patient does not have a cancer diagnosis, contact the prescriber and advise him or her that the medication is covered only for FDA- labeled indications. Discuss with the prescriber possible alternative options that are covered by Medicaid for the indication in question. Another group of drugs that may be prescribed for off-label uses are buprenorphine-naloxone products. These medications are indicated only for the treatment of opioid dependence, but are sometimes prescribed for other indications. Products containing buprenorphine-naloxone are FDA-approved for the maintenance treatment of opioid dependence and should be used as part of a complete treatment plan that includes counseling and psychosocial support. These products are partial opioid agonists, and their use is restricted under the Drug Addiction Treatment Act (DATA). This means only physicians who meet certain qualifying requirements and who submit an application for a DATA waiver can prescribe these drugs. Prescribers with a DATA waiver are assigned a unique identification number that they must include on every prescription. When a patient presents a prescription for a buprenorphine-naloxone product, verify the prescription was written by a prescriber in compliance with the DATA requirements. Verify the prescriber’s DATA 2000 waiver by consulting the Substance Abuse and Mental Health Services Administration’s website. If you determine a buprenorphine-naloxone product is being used to treat pain or any indication other than opioid dependence maintenance, inform the prescriber that the medication is only covered by Medicaid for FDA- approved indications. Discuss with the prescriber alternative options covered by Medicaid for the indication in question. Prescribers may write prescriptions for atypical antipsychotics to treat off-label indications. Atypical antipsychotic medications are used to treat a variety of FDA-labeled psychiatric conditions, including schizophrenia, bipolar disorder, and depression. However, off-label use of atypical antipsychotics has increased rapidly since their introduction in the 1990s. Quetiapine and olanzapine are among the most common atypicals prescribed for off-label use. Patients using medications for off-label indications is a real concern because of the significant potential for adverse effects. Most commonly prescribed off-label for insomnia, atypical (second- generation) antipsychotics offer very low or low efficacy and are an expensive treatment option for this use. In addition, Medicaid patients are at risk for sudden cardiac death and cardiac arrest when using them for sedation. This risk is particularly high in vulnerable pediatric and elderly populations. If you determine an atypical antipsychotic is being used to treat insomnia or to cause sedation, inform the prescriber that the medication is covered only for FDA-labeled indications and discuss alternative Medicaid-covered options. If appropriate, discuss alternative options such as benzodiazepines, or FDA-labeled sedative hypnotics such as zolpidem, zaleplon, or ramelteon Now let’s discuss one of the most rapidly growing prescribing practices – the prescribing of atypical antipsychotics for children. Antipsychotic medications prescribed for children is an issue confronting parents, other caregivers health care professionals, and related organized health care agencies across the United States. Due to the rising concerns of this prescribing practice, the OIG analyzed Medicaid claims in five States in 2014. The OIG identified quality-of-care concerns in 67 percent of claims for second generation antipsychotics that were prescribed for children. The table lists the quality-of-care concerns identified from OIG’s analysis and the percentage of claims affected by these concerns. Concerns include patients not provided with appropriate monitoring, patients prescribed the wrong treatment, patients prescribed too many psychotropic drugs at the same time patients taking the medication for too long patients given the wrong dose, young patient age, and side effects. So, how can you help prevent these concerns? Examine the indication the prescriber intends to treat when presented with a pediatric prescription for a second-generation antipsychotic. Remember that the FDA does not approve all second-generation antipsychotics for children. Of eight second-generation antipsychotics, six are approved by the FDA for use in children: aripiprazole, asenapine, olanzapine, paliperidone quetiapine, and risperidone. Approved indications include schizophrenia bipolar disorder, irritability associated with autism, and Tourette syndrome. In addition to FDA-labeled indications, risperidone also has compendial support for several additional indications. Risperidone also has compendial support for behavioral syndrome-mental retardation, pervasive developmental disorder and Tourette syndrome. In addition to FDA-labeled and compendially supported indications, pediatric use of atypical antipsychotics also includes off-label uses. Drug manufacturers do not often seek FDA approval for pediatric use. Consequently, SMAs may not have excluded them for use. The SMA may use the prior authorization approval process to ensure the drug is being prescribed for indications supported by current guidelines and literature. Let’s take a look at some off-label uses supported by the American Academy of Child and Adolescent Psychiatry. Anorexia, conduct disorder, disruptive behavior disorder for example, oppositional defiant disorder, obsessive-compulsive disorder and post-traumatic stress disorder are supported off-label uses. In addition, risperidone is used off-label for a wide variety of behavioral and psychological disorders, anorexia nervosa, impulse aggression control in conduct disorder, attention deficit hyperactivity disorder (ADHD) with aggression and disruptive behavior disorder, are off-label pediatric uses of risperidone. Children’s use of antipsychotics has increased dramatically over the past two decades. From 1993 to 2009, pediatric antipsychotic use rose from 0.24 per 100 to 1.83 per 100 children and from 0.78 per 100 to 3.76 per 100 adolescents, with the most common pediatric indication of ADHD or other disruptive behavior disorders. Prescribers and pharmacists must consider that the risk for a variety of significant side effects related to the use of antipsychotic medications appears to be major for children and adolescents. Pharmacokinetics including drug absorption, distribution, metabolism, and elimination
may differ in children and adults. Response to any drug may also vary based on factors such as age, sex, body size (weight or body mass index), genetics, and coexisting disease states. Pharmacists should discuss potential medical risks, and the risks associated with medication sharing, with the caregiver and should also initiate discussions with the child, when age-appropriate and given permission to counsel by the caregiver. Counsel the caregiver and the child to ensure they understand the purpose for the antipsychotic, actions, and anticipated benefit. Keep in mind that aggression, resistant ADHD, tic disorders, obsessive-compulsive disorder, eating disorders, depression, post-traumatic stress disorder, or insomnia are appropriate off-label indications in children. Tailor your counseling to the applicable drug prescribed. Make sure the caregiver is aware of potential risks for common or severe side effects. In particular, advise the caregivers to monitor children for these troublesome effects such as: Weight gain and other metabolic changes that may manifest as diabetes or hyperlipidemia; Cardiovascular changes, including increased heart rate or increased blood pressure; Prolactin elevation that may lead to amenorrhea, absence of menstruation, galactorrhea – milk discharge from the breast unrelated to breastfeeding in females or males, or gynecomastia – enlargement of breast tissue in males; or extrapyramidal side effects that are seen as akathisia – inability to sit still dystonic reactions – sustained involuntary
muscle contractions, or tardive dyskinesia – abnormal involuntary movements. Lastly, do not forget to explain the importance of close monitoring and prescriber follow-up. Let’s turn our attention to drugs that may be excluded from payment under the Medicaid program, beginning with PDEIs. PDEIs are used to treat FDA-labeled indications that include pulmonary arterial hypertension (PAH), benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). Federal law prohibits Medicaid coverage of PDEIs, such as sildenafil or tadalafil, to treat sexual dysfunction. Although States have measures in place in the pharmacy point-of-sale system to prevent the inappropriate dispensing of these medications, the potential for improper payments still exists. If a patient presents a prescription for a PDEI that is not labeled for ED, such as Revatio, automated verification measures in place may not catch the error. If you determine that a PDEI medication is being used for erectile dysfunction explain the exclusion to the patient and offer a self-pay cash option. The Medicaid program also excludes cosmetic purposes from coverage. Topical retinoids, such as tazarotene and tretinoin, are FDA-labeled to treat acne and plaque psoriasis. Some tazarotene and tretinoin products are also FDA-labeled to treat facial wrinkling. Injectable botulinum toxins are FDA-labeled to treat a variety of indications, including temporary improvement in the appearance of moderate to severe glabellar lines, also known as wrinkles. States may opt to exclude drugs or drug classes used for a particular indication outlined in section 1927(d)(2) of the Social Security Act. The use of topical retinoids or injectable botulinum toxins to treat wrinkles is excluded because it is considered a cosmetic purpose. If you determine a topical retinoid or botulinum toxin is being used for cosmetic purposes, explain the exclusion to the patient and offer a self-pay cash option for the prescription. Because weight loss is considered a cosmetic purpose, drugs prescribed solely for the purpose of weight loss are excluded from coverage under the Medicaid program. mimetic drugs work by mimicking the incretin hormones that the body usually produces naturally to stimulate the release of insulin in response to a meal. They are used along with diet and exercise to lower blood sugar in adults with type 2 diabetes. Studies have shown that these products have a favorable side effect profile in that they enhance weight loss. Liraglutide has shown in phase 3 trials to maintain weight loss over an extended period of time in overweight study participants who did not have diabetes. However, products used for weight loss are excluded from drug coverage. Although prescribers and patients may want to use these products to promote weight loss in obese Medicaid patients, pharmacists must inform patients about the exclusion. When a patient presents a prescription for an incretin mimetic, if you determine the medication is being prescribed for weight loss alone, explain that this indication is excluded for coverage and offer a self-pay cash option to the patient for the prescription. The last topic discussed during the prescribing practices portion of the self-audit involves drugs at risk for prescriptions intended for recreational use. Amphetamines and cannabinoids are prescription drugs commonly abused, and abuse of these drug types poses a serious public health concern. Due to the highly addictive nature and street value of these drugs, the potential for fraud and abuse is substantial. When a patient presents a prescription for an amphetamine or a cannabinoid, ensure appropriate prescribing of these medications by verifying that the patient understands the medication prescribed through the use of the IHS counseling technique. If you determine that the drug is being used for an off-label use, such as to enhance academic performance, treat depression, or enhance weight loss, explain that these are all excluded indications and offer a self-pay cash option to the patient for the prescription. You should exercise your corresponding responsibility and not fill the prescription if you determine the drug is being used for an illicit purpose or feel it may be diverted. If you have concerns about a prescription, you should report your concerns to the proper authorities. 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. 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 Review the following drug classes. Determine which of the off-label or excluded indications and appropriate covered use correspond from the options on the next slide. The correct answer for number 1. Atypical antipsychotics is B. Appropriate covered use: psychiatric conditions including schizophrenia, bipolar disorder and depression; off-label or excluded indication: insomnia or sedation. The correct answer for number 2. Amphetamines is C. Appropriate covered use: attention deficit hyperactivity disorder; off-label or excluded indication: enhance academic performance. The correct answer for number 3. Injectable incretin mimetics is A. Appropriate covered use: diabetes type II; off-label or excluded indication: weight loss. Let’s review a few more drug classes on the next slide. Choose the corresponding answer from the options provided. The correct answer for number 1. Transmucosal immediate release fentanyldrugs is C. Appropriate covered use: breakthrough cancer pain off-label or excluded indication: non-cancer pain. The correct answer for number 2. Buprenorphine-naloxone containing drugs is B. Appropriate covered use: maintenance of opioid dependence; off-label or excluded indication: chronic pain. The correct answer for number 3. Retinoids is D. Appropriate covered use: acne; off-label or excluded indication: glabellar lines and the correct answer for number 4. Phosphodiesterase inhibitors is A. Appropriate covered use: pulmonary arterial hypertension or benign prostatic hyperplasia; off-label or excluded indication: erectile dysfunction. CMS is committed to educating pharmacy providers about potential fraud, waste, and abuse related to pharmacy services. This is the first module in this 4-module self-audit series. The 4 modules provide a step-by-step analysis broken down into key areas: prescribing practices, controlled substances management, invoice management, and billing practices. In addition, the presentation modules address areas prone to potential fraud, waste, and abuse related to pharmacy services and provide instruction on how to report them. Pharmacy providers can use audit findings to identify areas of practice that require further scrutiny, as well as, use these tools to educate pharmacy personnel about potential fraud, waste, and abuse. This portion of the presentation discussed
how to incorporate an evaluation of prescribing practices into a pharmacy self-audit. Module 1 describes the first 12 of 50 steps and examines excluded providers, prescriptions written outside the provider’s scope of practice, and prescriptions written for off-label indications. You will protect the health and safety of your patients by understanding your responsibilities to them and the State Medicaid program. Proceed to Module 2 for a detailed examination of how to perform pharmacy self-audit of controlled substances practices. 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.

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