Your Pharmacy Solution

Ippc Pharmacy is continually striving to achieve the utmost in patient care and quality of service. It is our responsibility to advise all of our employees, patients, contractors and agents our efforts to help in the fight to prevent Medicaid/Medicare waste fraud and abuse. Please take note of the following examples below. Should you need to report any inappropriate action call 732-617-8686 ext 102, Denise Fogarty Rn. is the compliance officer. The complaint process will be initiated. Remember you have the right to remain anonymous.

PHARMACY FRAUD, WASTE AND ABUSE

The following section describes examples of Pharmacy fraud, waste and abuse. Examples of potential fraud, waste and abuse include but are not limited to:

INAPPROPRIATE BILLING PRACTICES: Inappropriate billing practices at the Pharmacy level occur when pharmacies engage in the following types of billing practices:
 

• Incorrectly billing for secondary payers to receive increased reimbursement.
• Billing for non-existent prescriptions.
• Billing multiple payers for the same prescriptions, except as required for coordination of benefit transactions.
• Billing for brand when generics are dispensed.
• Billing for non-covered prescriptions as covered items.
• Billing for prescriptions that are never picked up (i.e., not reversing claims that are processed when prescriptions are filled but never picked up).
• Billing based on "gang visits," e.g., a pharmacist visits a nursing home and bills for numerous pharmaceutical prescriptions without furnishing any specific service to individual patients.
• Inappropriate use of dispense as written ("DAW") codes.
• Prescription splitting to receive additional dispensing fees. Drug diversion.

   

• PRESCRIPTION DRUG SHORTING: Pharmacist provides less than the prescribed quantity and intentionally does not inform the patient or make arrangements to provide the balance but bills for the fully-prescribed amount.
• BAIT AND SWITCH PRICING: Bait and switch pricing occurs when a beneficiary is led to believe that a drug will cost one price, but at the point of sale the beneficiary is charged a higher amount.
• PRESCRIPTION FORGING OR ALTERING: Where existing prescriptions are altered, by an individual without the prescriber's permission to increase quantity or number of refills.
• DISPENSING EXPIRED OR ADULTERATED PRESCRIPTION DRUGS: Pharmacies dispense drugs that are expired, or have not been stored or handled in accordance with manufacturer and FDA requirements.
• PRESCRIPTION REFILL ERRORS: A pharmacist provides the incorrect number of refills prescribed by the provider.
• ILLEGAL REMUNERATION SCHEMES: Pharmacy is offered, or paid, or solicits, or receives unlawful remuneration to induce or reward the Pharmacy to switch patients to different drugs, influence prescribers to prescribe different drugs, or steer patients to plans
• TROOP MANIPULATION: When a Pharmacy manipulates TrOOP to either push a beneficiary through the coverage gap, so the beneficiary can reach catastrophic coverage before they are eligible, or manipulates TrOOP to keep a beneficiary in the coverage gap so that catastrophic coverage is never realized
• FAILURE TO OFFER NEGOTIATED PRICES: Occurs when a Pharmacy does not offer a beneficiary the negotiated price of a Part D drug. Reprinted from pp 58-59 of the Medicare Prescription Drug Manual - Chapter 9 - Part D Program to Control Fraud, Waste and Abuse