Allowable Changes by a Prescriber to an Original PrescriptionBackground: OPA began receiving numerous complaints concerning a major third-party payer that was auditing Ohio pharmacies. In each case, the auditor(s) were asserting that properly documented changes, made by the pharmacist to an original prescription, per the direction of the prescriber, were illegal per Ohio Pharmacy Law. The third-party payer further alleged such illegal prescriptions were non-reimbursable, and that no documentation would be accepted to refute the findings of the audit. Finally, the third-party payer included these hotly contested "discrepancies" in the calculation of a ratio, always to the detriment of the pharmacy, which was interpreted by the third-party payer as permitting it to extrapolate the amount recouped from the pharmacy. It goes without saying that the third-party payer was all to willing to withhold the extrapolated recoupment from a pharmacy's future remittance if the pharmacy challenged the audit results.
It bears noting that OPA has in the past commented that the auditing of third-party claims is logical and makes good business sense, considering the fact that the payers are remitting for services sight unseen. The payer receives no tangible benefit, no proof that services really did take place. Thus, just as a good auto mechanic has the parts which were replaced available for the customer's inspection, pharmacists should be prepared to have the necessary documentation concerning a third-party prescription available for review by third-party auditors. Similarly, it bears noting that OPA works to maintain a healthy working relationship with third-party payers, striving to strengthen lines of communication to facilitate constructive dialog. In line with this mindset, OPA attempted to interact with the third-party payer to clear up the misinterpretation of the third-party payer and its auditors. Unfortunately, the third-party payer was unreceptive to OPA's efforts, categorically insisting the validity of the erroneous allegations.
OPA's next tack was to request written documentation from the Ohio State Board of Pharmacy specifically detailing the opinion of the Board [click here for text], as well as the Ohio Administrative Code (OAC) Rule(s) on which the position was based. OPA felt it would be very beneficial for the entire Board to be involved in setting the opinion, and that the Board's discussion of the issue should be documented in the official minutes of the Board. Thus, OPA requested a Board opinion for the requirements of when a new prescription is necessary and what changes to a prescription may be made by a verbal order from the prescriber after a written prescription has been issued.
Response: The State Board of Pharmacy's staff was very helpful in both facilitating the obtaining of a Board opinion and promptly providing documentation [click here for text]. The crux of the opinion indicated:
Any prescription, other than a schedule II drug, may be orally transmitted by the prescriber or the prescriber's agent, OAC 4729-5-30(K). Thus, if there is a question with any part of the prescription, prior to the original dispensing, the pharmacist may orally contact the prescriber and obtain clarification. This clarification may be documented or the pharmacist may simply create a new oral prescription. This would include authorization for "Dispense as Written". The Board's rules do not specifically state how to document the information. If the pharmacist has corrected part of a prescription prior to the original dispensing and there is documentation of the change, the Board would accept this as long as the prescriber acknowledges that they authorized the change.
Discussion: Clearly, it is the Ohio State Board of Pharmacy's opinion that authorization for "Dispense as Written" may be documented on the original prescription, by the pharmacist, pursuant to orally contacting the prescriber and obtaining clarification (so long as the prescription is not for a schedule II drug). The Board does not view this clarification/correction by the pharmacist any differently than any other clarification/correction.
Going Forward: If your pharmacy was one of the many pharmacies affected by an audit where Ohio Pharmacy Law was misinterpreted regarding changes you made to a written, issued prescription based upon verbal clarification/correction from the prescriber, request that the third-party payer reopen the audit for appropriate correction and monetary adjustment. If your pharmacy is scheduled for a third-party audit, have a copy of this article available for the auditor in an attempt to prevent further misinterpretation.
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June 14, 2016
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