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Audit Alert: Are You Billing the Correct NDC?

08/09/2021 11:57 AM | Anonymous member (Administrator)

By Trenton Thiede, PharmD, MBA
PAAS National

PAAS National is once again seeing recoupment on audits when a pharmacy bills the wrong NDC for the product dispensed. Unit-of-use packages like test strips, inhalers, and topical medications tend to have the most errors and are easily targeted on audits.

If the quantity billed does not match the product size indicated by the NDC, some PBMs will charge back the entire claim! This can be true whether billing 45g on a topical that come as a 50g tube or billing the NDC for 50-count test strips and dispensing the 100-count package size (potentially leading to invoice audit errors or additional cost to plan). PBMs go after the latter when the cost of dispensing the larger package size is less than the cost for two smaller size packages. The pharmacy is expected to dispense the package size that costs less for the plan.

PAAS Tips:

  • Implement barcode scanner technology for product verification to prevent misfills
  • Dispense the correct package size, closest to what the prescriber indicated, without going over the written quantity
  • For topical medications, ensure the quantity billed matches tube size dispensed
    • For example, do not submit the NDC for a 28 g tube but bill for 30g
    • Often, the last 2 digits of the NDC match the package size
  • Contact the prescriber to confirm changing the quantity to the accurate manufacturer package size, especially if that package size is larger than originally prescribed
  • If you need to dispense two smaller package sizes because the larger package size is backordered (e.g., dispensing two 15g tubes instead of a 30g tube), document this and print proof from your wholesaler that the larger package size was unavailable and attach it to the prescription
  • If you are out of stock on the quantity prescribed but can order it from your wholesaler, do so if the patient can wait for it to come in
    • If the patient cannot wait due to a true clinical need, document this on the hard copy
  • Consider flagging shelves containing high risk items for package size errors to remind staff to doublecheck

Trenton Thiede is president of PAAS National, an expert third-party audit assistance and FWA/HIPAA compliance. PAAS National is committed to serving community pharmacies and helping keep hard-earned money where it belongs. Contact us today at (608) 873-1342 or to see why membership might be right for you.

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