Background and Frequently Asked Questions - Pharmacare Audit and Investigations

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1 Infrmatin fr Pharmacists Backgrund and Frequently Asked Questins - Pharmacare Audit and Investigatins Effective August 18, 2017 Backgrund: Manitba cntinually reviews and updates regulatins, plicies, and prcedures and changes may be made t these frm time t time. When changes are apprved by the minister, Manitba sends a cmmunicatin t all Manitba pharmacies utlining any changes. These ntices shuld be included in yur pharmacy s Drug Prgrams Infrmatin netwrk (DPIN) Manual under Sectin 4: Claims Submissin. Claims that are nt cmpliant with the effective date nted n the reimbursement prcedure(s), are subject t audit and recvery. Please nte that pharmacy sftware changes may be required by the pharmacy prvider. This is the respnsibility f the pharmacy prvider. Fr example, pharmacy prviders shuld check their sftware slutin (e.g. Krll), as smetimes the sftware autmatically adds a prfessinal fee t each transactin which may nt be cmpliant with Manitba reimbursement requirements. Manitba may, at its ptin and at any time, cnduct a review r audit the accunts and recrds f the pharmacy prvider relating t any claim submitted by the pharmacy t determine whether the pharmacy has cmplied with the terms and cnditins f the Pharmacy Agreement. Cmpliance with the Pharmacy Agreement includes receipt and apprval f Schedule A - Cnfirmatin f Prfessinal Fees r Schedule B Ntice f Prfessinal Fee Change as described in Sectin 3 Claims Submissin f the Pharmacy Agreement. Any review r audit will be cnducted by Manitba s auditrs, inspectrs r representatives in accrdance with Sectin f the Pharmacy Agreement. NOTES: Currently accepted/apprved Schedule A r Schedule B dcuments n file with Manitba will cntinue t be recgnized and capped accrdingly as per the amendment t The Prescriptin Drugs Payment f Benefits Regulatin effective August 18, Please see specific Claims Submissin Prcedures fr additinal infrmatin. Manitba des nt allw mark-ups just a prfessinal fee (als referred t as the Usual and Custmary Fee ). Fr pharmacies that have submitted Schedule A r B dcuments that include reference t a percentage (%) mark-up + a prfessinal fee the mark-up will be remved. Updated - August 2017 Page 1 f 6

2 In the case where the prfessinal fee is nted as: Drug Csts ver $X 10 % mark-up this will be replaced with: Drug Csts ver $X 10% f actual acquisitin cst (AAC) if, fr whatever reasn, the amunt submitted in DPIN is less than the AAC, the amunt submitted in DPIN will be used fr audit purpses. The fllwing are sme examples f remuneratin f prfessinal fees nt cmpliant with established plicy and subject t recvery. If any f these fees are listed n existing Schedule A r Schedule B dcuments they will be eliminated: Fees f a cgnitive services nature and may be nted as fees fr pharmacists time (this includes but nt limited t cunselling [smking cessatin, diabetes cunselling, diabetes meter training, exceptinally difficult patient etc.], in-huse cnsultatins [ huse-calls ], care plans, chrnic and special disease state management, patient based written pharmacist pinin with references, patient assessment in medicatin related emergency, cntinued care, assessment fee fr exempted cdeine prducts, medicatin reviews etc.) Additinal fees fr packaging frmats such as blister packaging, pre-filled syringes, etc. all packaging frmats will be n parity with existing usual and custmary prfessinal fees Additinal fees fr small quantities r, special rder pharmaceuticals Fees fr flavuring i.e. reflavuring f an existing marketed prduct Fees fr the inclusin f ver-the-cunter medicatins (OTCs) in blister packaging Fees fr injectin administratin (NOTE: publicly funded vaccines t be prcessed as per current prcess/plicy) Fees fr pharmacist prescribing including the prescriptin fr minr ailments Fees fr nurse practitiner r hmecare visits, family cnsultatins r case management cnference etc. Fees fr dse witnessing Fees fr manual billings Fees fr ther value added services, ther clinical fees that may be charged frm time t time Fees fr medicatin recnciliatin fr physicians, applying fr Exceptin Drug Status (EDS) Fees fr telephne/fax/ cmmunicatins with prescribers Fees fr clzapine mnitring Fees fr staff, dctr, family rates, cmpetitive match r cmpetitive fee rates, cmpassinate reasns, prfessinal curtesy etc. Fees fr refusal t fill Fees fr medical supplies and equipment retail that includes BOTH a percentage (%) f cst, and a prfessinal fee Fees fr after hur service r emergencies Any fee differentials fr cash paying custmers What happens if there is a discrepancy between the Schedule A r B n file with Manitba and the Schedule A r B being used by a pharmacy? In the case f a discrepancy in the recrds related t Schedule A and /r B that a pharmacy has and what is n file with Manitba. The Schedule A and/r B f recrd held with Manitba will be the fficial infrmatin that will be referred t. This infrmatin supersedes all ther recrds. Updated - August 2017 Page 2 f 6

3 It is the respnsibility f the pharmacy t keep and maintain all recrds related t submitting the riginal Schedule A and subsequent Schedule B. This wuld include but nt limited t date stamped, fax cnfirmatin and s. In additin, all ntificatins related t the apprval r rejectin f a Schedule shuld be retained by the pharmacy. In any case the cpy n recrd with Manitba will be the fficial recrds and supersedes all ther recrds. What is the Pharmacy Claims Audit Plicy? Any services, specified drugs r benefits prvided by Manitba and all claims that are adjudicated t, r reimbursed in whle r in part by any Manitba prgrams are subject t audit t cnfirm cmpliance with the prvisins f the Pharmacy Agreement and applicable Manitba plicies, prcedures and regulatins. What is the purpse f the Audit Plicy? The purpse f the audit plicy is t establish the prcess t cnfirm that the details f a claim submitted under the prgrams cmply with the crrespnding prescriptin n file in the pharmacy and t supprt verall effective peratins f the prgrams. Prescriptins are audited by Manitba t: Verify that claims have been paid fr valid prescriptins Verify that the claimed item was dispensed as per the prescribers dispensing instructins Ensure that claims were submitted in accrdance with prgram plicies and prcedures, applicable legislatin and any agreements Wh will be cnducting the primary and cmprehensive audits? Audits are perfrmed by Manitba Audit Investigatin Unit staff and appinted by the minister as a duly authrized inspectr under The Prescriptin Drugs Cst Assistance Act and The Health Services Insurance Act fr the purpses f cnducting audits. Hw will I be ntified if my pharmacy will be audited? Pharmacies will be sent a frmal ntice f an audit identifying the type f audit that has been identified. They will be asked t schedule primary and cmprehensive audits within tw (2) weeks and have them cmpleted within six (6) weeks (suggested dates and times will be prvided). Once the primary r cmprehensive audit has been scheduled, a ntificatin letter cnfirming the auditr and audit date and time will be sent t the pharmacy. As a reminder, the pharmacy will be cntacted a few days prir t the audit, t cnfirm the audit details. Manitba will take all reasnable steps t ensure that a primary r cmprehensive audit is nt cnducted during Pharmacare year end r during majr hlidays. Hw are pharmacies selected fr Audit? Selectin f a pharmacy fr audit may be made by statistical analysis and cmparisn f claims data, randm selectin, and/r direct selectin. What type f Audits will be cnducted? 1. Desk Audit this is a randm r direct selectin audit where pharmacies will be asked t prvide cpies/faxes which pertain t r substantiate the sampled claims. 2. Rutine Cmpliant Audit this is a randm r direct selectin audit t identify ptential cmpliance issues where pharmacies will be asked t prvide cpies/faxes which pertain t r substantiate the sampled claims. Updated - August 2017 Page 3 f 6

4 3. Special Purpse Audit this audit is based n statistical analysis and cmparisn f data claims such as: High vlume claims High dllar value claims General data analysis (abnrmal billing patterns) Clse prximity claims Extempraneus preparatin (cmpunds) 4. Primary Audit Sample sizes fr this audit will be based n the vlume f annual claims submitted by the pharmacy prvider. Claims are randmly selected fr review. This size may increase depending n the scpe f the review and the sampling methdlgy required t test cmpliance with Manitba billing prcedures r plicies. If significant billing issues are fund, the audit prceeds t a cmprehensive audit. 5. Cmprehensive Audit this audit reviews apprximately duble the number f primary audit claims. The size may increase depending n the scpe f the review and the sampling methdlgy required t test cmpliance with Manitba billing prcedures r plicies. 6. New Pharmacy Audit this audit may be dne t identify and crrect billing issues at an early stage. They will be cnducted at apprximately 6-12 mnths after the pharmacy has cmmenced peratins. 7. Clsed Pharmacy Audit - this audit may be cnducted after a pharmacy has clsed permanently, r when there is a change f wnership r sale. Manitba will withhld the pharmacy s last electrnic fund transfer (EFT) payment until an audit is cnducted f the claims submitted. Once cmplete, the funds will be frwarded t the pharmacy plus/minus any irregularities fund. Hw ften can I be audited? Primary and Cmprehensive Audits will be limited t nce every tw (2) years per pharmacy wner, per lcatin. Desk audits, rutine cmpliance audits and special purpsed audits may be cnducted at any time and as ften as necessary t ensure cmpliance with Manitba billing prcedures and plicies. If I am audited - hw will I be ntified f the audit results? Manitba prepares a Draft Audit Reprt fr all audits it perfrms. A written reprt f the audit will be sent t the pharmacy within 60 days f the date f such an audit. The Draft Audit Reprt identifies: The results f the audit and the methdlgies used t determine the results; An audit recvery amunt due t Manitba fr all disallwed r verbilled claims and the methdlgy used t calculate the recvery (if required); and Crrective actin plan (if required). What happens if a pharmacy claim is disallwed? If n recrds exist t supprt a claim, r the dcumentatin supprting a claim is incmplete r insufficient, the claim will be disallwed and any amunt assciated with the claim will be wing t Manitba. Can a pharmacy dispute disallwed claims identified in the draft audit reprt? If there are findings in the reprt that may result in Manitba recvering any claim, the pharmacy will have up t 30 days t submit a written respnse disputing any r all f such findings with infrmatin r dcumentatin t supprt the disallwed claims, r additinal infrmatin that may be relevant, r that may have been verlked during the audit. Please nte: Infrmatin a pharmacy slicits frm a prescriber r pharmacy after an audit, cannt be used t supprt a disallwed prescriptin claim. Updated - August 2017 Page 4 f 6

5 Pharmacy respnses t Draft Audit Reprts are reviewed, in all r in part, fr inclusin in the Final Audit Reprt. When will I receive the Final Audit Reprt? Manitba will send a Final Audit Reprt t the pharmacy within 60 days f receiving the written respnse frm the pharmacy. Please nte that results f audits may be referred t the Cllege f Pharmacists f Manitba (CPhM) r ther regulatry bdies, if deemed apprpriate. Hw d I repay a disallwed claim? In the event that an audit results in a recvery f paid claims, the pharmacy has up t 30 days in which t pay Manitba the full amunt f the verpayment identified by Manitba. If the pharmacy fails t remit payment in full t Manitba within such 30-day perid, Manitba may, in additin t any ther remedies available, withhld payment f any future claims t the pharmacy until such time that the verpayment is paid in full t Manitba. Once a recvery amunt is 30 days verdue it becmes subject t interest. What will happen t the infrmatin that is prvided during an audit? Manitba has security plicies and prcedures gverning the strage and destructin f infrmatin btained during the curse f business. Manitba must als adhere t strict cnfidentiality plicies and prcedures. These plicies are designed t prvide a high level f assurance that all infrmatin received as part f an audit will be kept in strict cnfidence. Shuld an auditr remve any recrds frm a pharmacy (r the lcatin where the recrds are kept) they will cmplete a Temprary Remval f Dcuments frm and leave a cpy with the pharmacy manager. The recrds will be returned within five (5) business days. What is the timeline fr Manitba t apprve Schedule B submissins? As delineated in the summary table belw: Schedule B submissins must be received by Manitba by 4:00 p.m. n the 15 th day f the mnth, six weeks prir t the Effective Date (as nted belw). Time f receipt will be determined by the date and time stamp printed n the fax r . Manitba will nt cnfirm the receipt f each Schedule B; pharmacies can expect t receive a respnse letter with either apprval r request fr clarificatin f their Prpsed Schedule B within apprximately10 business days f Manitba receiving a submissin. Manitba will wrk with pharmacy prviders t clarify errrs and missins between the 15 th and 1 st f each respective cycle. Prfessinal fee schedule changes can nly be applied t claims upn receipt f the final apprval letter and beginning n the specified Effective Date. Any claims submitted that include prfessinal fees nt apprved by Manitba will be subject t audit and recvery, Cycle Schedule B Receipt Deadline Schedule B Apprval by Schedule B Effective Date is 4:00 pm n: Manitba by: One February 15 (r next business March 1 (r next business day if April 1 day if the 15 th is a hliday) the 1 st is a hliday) Tw April 15 (r next business day if May 1 (r next business day if the June 1 the 15 th is a hliday) 1 st is a hliday) Three June 15 (r next business day if July 2 (r next business day if the August 1 the 15 th is a hliday)* 2 nd is a hliday)* Fur August 15 (r next business day September 1 (r next business Octber 1 if the 15 th is a hliday) day if the 1 st is a hliday) Five Octber 15 (r next business Nvember 1 (r next business December 1 day if the 15 th is a hliday)* day if the 1 st is a hliday)* Six December 15 (r next business day if the 15 th is a hliday) January 2 (r next business day if the 2 nd is a hliday) February 1 *Fr 2017 nly, Cycle Fur intake will be extended until 4:00pm n September 15, Updated - August 2017 Page 5 f 6

6 If yur questins are nt answered by reviewing the Claims Submissin Prcedures and FAQs psted at: Please send an t PDPInfAudit@gv.mb.ca. Updated - August 2017 Page 6 f 6