Details matter when billing Medicaid

As the Texas Health and Human Services Office of Inspector General comes across a specific concern, we would much rather providers learn about it before they receive an audit finding or notice of overpayment. If issues can be prevented before they occur, both the State of Texas and Medicaid providers can save valuable resources and avoid unnecessary headaches.

With the phone ringing, customers at the counter and an endless flow of prescriptions to fill, record-keeping is often the first to suffer: Will it matter if a prescription transcribed over the phone isn’t initialed?

Pharmacists know how important accuracy is, and that extends to record-keeping. Managing accurate and detailed documentation is one of the best things you can do to protect yourself and your patients.

Recently, the OIG encountered a situation where a pharmacy did not identify the transcribing pharmacist on prescriptions ordered over the phone. In this case, the seemingly minor omission affected well over $100,000 of billing to Medicaid that could be potentially recouped.

From medications that have similar names to simple transcription errors, communicating prescriptions over the phone can be problematic as is. If the transcribing pharmacist — or the person calling in the prescription — is not recorded, it can cause further complications by making it more difficult to notice or fix inaccuracies.

To maintain the chain of custody and protect all involved, the Texas State Board of Pharmacy specifies exactly what should be on every prescription in Texas Administrative Code Title 22, Section 291.34. If the prescription is faxed, delivered electronically or communicated by telephone, additional requirements apply such as:

If a faxed prescription:

• A statement that indicates that the prescription has been faxed (e.g., faxed to).
• The name of the designated agent, if transmitted by a designated agent.

If electronically transmitted:

• The date the prescription drug order was electronically transmitted to the pharmacy, if different from the date of issuance of the prescription.
• The name of the designated agent, if transmitted by a designated agent.

If communicated orally or telephonically:

• The initials or identification code of the transcribing pharmacist.
• The name of the prescriber or prescriber's agent communicating the prescription information.

Participation in Medicaid stipulates that providers also follow the rules set forth by governing bodies such as the Texas State Board of Pharmacy. When the OIG conducts an audit or investigation, it verifies that the pharmacy is in compliance.

Besides what is required on the prescription itself, other record-keeping requirements are no less important. Pharmacy providers should regularly review the rules and stay abreast of changes through continuing education.

Meticulous attention to record-keeping requirements is not only a vital part of providing quality care for your patients, but it will also pay dividends when it comes time for your next interaction with the OIG.

If you notice a discrepancy, it is also advantageous to self-disclose the error to the OIG. Providers and pharmacy benefit managers may call 1-800-436-6184 or visit ReportTexasFraud.com to report compliance issues.