AR MEDICAID SYNAGIS AUDIT

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AR MEDICAID SYNAGIS AUDIT

• Medicaid Pharmacy Program and
• Medicaid Program Integrity
• Pamela Ford, P.D., MBA
• NAMPI Aug. 30, 2009-Sept 2, 2009

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Summary Why Audit Synagis?

• Pharmacy Program Requires Prior Authorization for
  Synagis Using a Manual Review Process
• Synagis Not An Easy Drug To Audit
• Doses are weight based and can change each month
  Each PA entered for specific NDC
• Large Specialty Pharmacies Present a Challenge
  are Usually Out-of-State and Mail to Prescribing
  Physicians Office

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Summary Why Audit Synagis?

• AR Medicaid spent 6.4 million for 2007-2008 RSV
  season (5 months)
• Synagis ranked 4th in Top 25 Drugs Based on
  Total Claims Cost for 4Q2007 (10/1/07 -12/31/07)
• Synagis ranked 2nd during the peak RSV Season in
  Top 25 Drugs Based on Total Claims Cost for
  1Q2008 (1/1/08-3/31/08)

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Summary Why Audit Synagis?

• AR Medicaid Pharmacy Program Reimbursement Rates
  
• 2007-2008 RSV Season
• 50 mg/0.5 ml 829.98 100 mg vial 1,567.22
• 2008-2009 RSV Season, reflects a 9.9 increase
• 50 mg/0.5 ml 912.14 100 mg vial 1,722.37
• 2009-2010 RSV Season, reflects a 12.5 increase
• 50 mg/0.5 ml 1026.15 100 mg vial 1,937.67

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Summary Synagis PA Requests
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The Audit Process

• Pharmacist in Medicaid Pharmacy Program Performed
  the Audit
• The Audit Required the Dispensing Pharmacy to
  Submit All Synagis Records for RSV Season 07-08
• Some pharmacies included verification form from
  physicians and some pharmacies records were
  lacking
• Follow-up Requests for Data Sent to Prescribers
  and Home Health Agencies
• Confirmation Patient Received Dose
• Actual Dose Given to Patient
• Date Dose Given to Patient
• Next Scheduled Appt?

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The Audit Process

• Pharmacist reviewed data comparing 4,299 claims
  against data submitted by Pharmacies and
  Prescribers
• Calculated appropriate dose for weight
• Compared claims data to what should have been
  dispensed for an appropriate dose (by weight)
  checked confirmation patient received dose

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The Audit Process

• Results of Each Pharmacy Audit Turned Over to
  Program Integrity for Review Through Their
  Process Prior to Mailing
• 11 Pharmacies Included in Synagis Audit3 had
  perfect audit (1.33 of claims)

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The Audit Process

• AR Medicaid Provider Manual states Providers
  have the right for an administrative
  reconsideration within 30-calendar days of
  receiving notice of an adverse decision/action.
  The Request must be in writing and include addl
  documentation.
• Providers also have the right to request a legal
  appeal within 30-calendars of receiving the
  notice of adverse decision/action, or 10-calendar
  days of recv administrative reconsideration
  decision.

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Preliminary Results
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Two Main Findings

• Child Never Received Dose
• Too Many Vials / Inappropriate Dose Sent for
  Childs Weight

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Challenges of the Synagis Audit

• Not a routine Pharmacy Desk Audit
• Not a question of whether or not the pharmacy
  shipped what was billed
• The Audit Uncovered a Question of Professional
  Judgment
• Was the correct dose shipped for the weight?
• Should the dose have been shipped without a next
  scheduled appt verified?
• Should the pharmacy verify the unused drug left
  in the physician's office before shipping more?

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Lessons Learned

• AR State Board of Pharmacy Regulations Prohibit
  Medications Requiring Refrigeration from Being
  Returned for Re-Use.
• Pharmacy Program and Program Integrity sought DHS
  legal counsel on several of these claims in the
  Reconsideration process.

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Lessons Learned Child Never Received Dose

• Medicaid Pharmacy Program Policy Requires
  Signature for Receipt of Drug. Drs Office
  signing for drug for pt is no different than wife
  signing for husband.
• Pharmacy Program policy did not require
  documentation of scheduled appointment before
  shipping dose. Cannot penalize.

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Lessons Learned Too Many Vials/Inappropriate Dose

• Reconsideration Requests Claims Involving Dose
  Were Re-Reviewed and Recalculated Using Weight
• Can include claims in questioned cost if dose
  sent was clearly too much for anticipated weight
  gain.
• The extra un-used vial(s) was tracked in the
  claims
• If extra later used, not counted against
  pharmacy.
• If the pharmacy continued to bill inappropriate
  qty/dose, these remained as Questioned Costs in
  the Audit against the pharmacy.
• April dose billed in March-policy did not state
  could not bill twice in March or state a maximum
  of 5 doses. Cant include these claims in
  questioned costs.

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Corrective Action Plans

• Pharmacies That Requested Reconsideration
  Required to Develop Corrective Action Plans on
  All Deficiencies Found in Audit.
• DHS Pharmacy Program Developed a Corrective
  Action Plan for PA Process for Upcoming Season.

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DHS Corrective Action Plan

• Beginning with RSV Season 09-10, Each PA
  Approval Will Be Entered For One Dose At A Time.
• Synagis PA Process Will Require Prescriber to FAX
  Medicaid Documentation of Appointment Form to
  EDS.
• Each Fax-Back Form Must Include Date Dose
  Given, Actual Dose Given, Current Weight, Date of
  Next Scheduled Appt.

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DHS Corrective Action Plan

• Each Medicaid Profile Checked Prior to New PA
  Entered. Dose Sent Compared to Dose Given.
• Each PA Approval For the Next Scheduled Appt Will
  Be Entered for Specific Dose. If Extra Vial
  Remains at Clinic, PA Will Not Be Approved For
  That Vials Str.
• PA Will Be Entered 1 Week Prior to Next Scheduled
  Appointment.
• PA Form Clearly States Maximum of 5 Doses for
  Season, Depending On Criteria.

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Future Audits

• Synagis Audit Will Be a Yearly Audit
• RSV 2008-2009 Season Audit underway, Records
  Collected from both Pharmacy Providers and
  Prescriber Providers
• Audits sent to Program Integrity for Review
• Pharmacies policing themselves Already seeing
  fewer questionable costs
• RSV 2009-2010 Season Audit will begin immediately
  after season ends March 2010.
• Will be spot-checking during season. Anticipate
  no problems.

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PA Criteria Changes for 09-10

• AR PA Criteria Changed for RSV 2009-2010 Season
• AAP RSV Guideline Recommendations Changed June
  2009
• 32 wk 0 day to 34 wk 6 day EGA, recv up to a max
  of 3 injections up to 90 days of age
• Risk factors changed to two specific criteria
• Siblings lt 5 yrs, OR Daycare AttendanceMust
  have at least one.
• AR will require names and ages of siblings, and
  name, address, and phone number of daycare

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• QUESTIONS