Pharmacy Self-Auditing: Control Practices to 
                          Improve Medicaid Program Integrity and Quality  
                                                                                         Module 4 
                                                                                   Billing Practices 
                                                                                             Objectives 
                          At the conclusion of “Module 4: Billing Practices,” 
                          the learner will be able to: 
                               • Identify three common reasons for billing errors.  
                               • Recall two types of inappropriate refill practices. 
                        Centers for Medicare & Medicaid Services                                                    2 
                                                                          Self-Audit Process 
                          Use of the self-audit process allows pharmacy staff to: 
                               •  Evaluate daily practices. 
                               •  Pinpoint audit triggers. 
                               •  Address vulnerabilities. 
                          Materials to gather before beginning the billing practices self-audit: 
                               •  Signature logs. 
                               •  “Pharmacy  Auditing  and  Dispensing  Job  Aid:  Billing  Injectable 
                                  Formulations”. 
                               •  “Pharmacy Auditing and Dispensing Job Aid: Billing Kits”. 
                               •  “Pharmacy Auditing and Dispensing Job Aid: Billing Oral Formulations”. 
                               •  “Pharmacy Auditing and Dispensing Job Aid: Billing Other Dosage Forms”. 
                        Centers for Medicare & Medicaid Services                                                    3 
                                                                                                                                                                                                                                                    1 
                                             Billing Practices Self-Audit 
                      • Pharmacists’ role. 
                      • Audit purpose. 
                      • Job aids: injections, kits, oral products and other 
                         dosage forms. 
                    Centers for Medicare & Medicaid Services                                   4 
                                             Prescription Requirements 
                      • Non-controlled. 
                      • Controlled. 
                    Centers for Medicare & Medicaid Services                                   5 
                                                                        Calculations 
                      • Quantity to be dispensed. 
                      • Days’ supply. 
                    Centers for Medicare & Medicaid Services                                   6 
                                                                                                                                                                                                        2 
                                                                    Odd Quantities 
                      Correctly adjust the days’ supply. 
                    Centers for Medicare & Medicaid Services                                   7 
                                                                          High Doses 
                     • Verify high doses with prescription product labeling 
                        at: 
                        o http://dailymed.nlm.nih.gov/dailymed/index.cfm 
                        o https://www.accessdata.fda.gov/scripts/cder/drugsatfda/ 
                     • Verify  doses  that  exceed  labeling  with  the 
                        prescriber. 
                     • Document all communication. 
                    Centers for Medicare & Medicaid Services                                   8 
                                                                  Use as Directed 
                      • Shampoos. 
                      • Creams and ointments. 
                      • Migraine medications. 
                      • Insulin. 
                      • Diabetic syringes, test strips, or lancets. 
                    Centers for Medicare & Medicaid Services                                   9 
                                                                                                                                                                                                        3 
                          Pharmacy-Driven Inappropriate Refill 
                                                                              Practices 
                      • Push-billing when auto-refilling.  
                      • Patient consent. 
                      • Financial incentives.  
                      • Waiving co-pays.  
                    Centers for Medicare & Medicaid Services                                   10 
                               Patient-Driven Inappropriate Refill 
                                                                              Practices 
                      • Stockpiling. 
                      • Diversion. 
                      • Red flags of diversion. 
                    Centers for Medicare & Medicaid Services                                   11 
                                                   Inappropriate Overrides 
                      • Prior authorization. 
                      • Vacation. 
                    Centers for Medicare & Medicaid Services                                   12 
                                                                                                                                                                                                        4