The OIG audited MCO claims payments made to a Texas pharmacy
The OIG conducted an audit of Medicaid managed care claims paid to Rx Plus Pharmacy of Live Oak (Rx Plus) by Superior HealthPlan, Inc., a managed care organization. During the period from June 1, 2017 through August 31, 2019, Rx Plus was paid $3.3 million for 27,462 Medicaid managed care claims for prescriptions dispensed to Superior members. The audit objectives were to determine whether Rx Plus (a) properly billed for paid claims associated with Medicaid members enrolled with Superior and (b) complied with applicable contractual, state and federal requirements.
Rx Plus properly billed for claims and complied with applicable contractual and Texas Administrative Code requirements for all refill claims and most initial fill claims selected for testing as part of this audit. However, for two initial fill claims, Rx Plus did not properly bill for the claims or consistently comply with applicable requirements for Medicaid managed care pharmacy claims. Specifically: (a) for one of 120 initial fill claims tested, the medication dosage direction on the prescription did not agree with the medication dosage direction dispensed and (b) for one of 120 initial fill claims tested, Rx Plus submitted the claim with an incorrect issuance date, although the prescription was still valid.