NIHB Audit Toolkit For Manitoba Pharmacies

Nihb Audit Toolkit For Manitoba Pharmacies-Free PDF

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TABLE OF CONTENTS,Introduction 4,Role of MSP 5, Non Insured Health Benefits Audit Program Overview 6. General Audit Recovery Prevention 7,Provider Information Changes 8. Coordination of Benefits 8,Components of a Prescription 9. Prescription Changes Interventions and Overrides 10. Extemporaneous Mixtures 11,Methadone Compounds 13,Audit Recovery Prevention Tips 14. Audit Preparation 17,Audit Checklist 18, Appendix A Audit Findings and Recovery Activities 20.
Appendix B NIHB Pharmacy Claims Submission Kit Section 8 24. Appendix C Express Scripts Pharmacy Provider Agreement Section 6 27. Appendix D Audit Findings and Recovery Actions NIHB Pharmacy Provider. Audit Program 28,Appendix E Coordination Benefits Bulletin 30. Appendix F Relevant Legislation Express Scripts Canada 33. Appendix G Audit Notification Letter 35,Appendix H Useful Websites 37. DISCLAIMER, This Toolkit has been developed by the Manitoba Society of Pharmacists for the. sole purpose of supporting member pharmacists It is an interpretation of NIHB. policy and procedures in place at the time of publish It does not replace or. supersede NIHB policy and procedures Pharmacists are responsible to. understand and stay current with NIHB policy by referring to the following. NIHB Pharmacy NIHB Claims Submission Kit and the Express Scripts Pharmacy. Provider Agreement found on the Express Scripts NIHB Pharmacy Provider. website http www provider express scripts ca pharmacists html It is also. available on the MSP website at, http www msp mb ca PDF 3rdParty NIHB Pharmacy Claims Submission Kit p. NIHB Provider Guide for Pharmacy Benefits found http www hc. sc gc ca fniah spnia pubs nihb ssna drug med 2010 prov fourn guide index. eng php It is also available on the MSP website at. http www msp mb ca PDF 3rdParty Provider 20Guide 20for 20Pharmacy 2. 0Benefits pdf, Express Scripts Canada produces a quarterly newsletter that is available at.
http www express scripts ca research health newsflash newsletters Members. are encouraged to bookmark this site and check it quarterly for any changes or. These documents can also be obtained by contacting the MSP office or. accessing the Members area of the MSP website,ACKNOWLEDMENTS. MSP would like to thank the following for their help in developing the Toolkit. The Pharmacists Association of Saskatchewan PAS, MSP members Keith Clark Gerald Thiessen and Heather Langtry. MSP Board Members Gregory Harochaw Mel Baxter Gayle Romanetz. Alison Desjardins Alan Lawless Scott McFeetors and Amy Oliver. Express Scripts Canada website consultation,Health Canada. INTRODUCTION, Each year a number of Manitoba pharmacies receive notification that their Non. Insured Health Benefit NIHB beneficiary prescriptions will be subject to audit. Audits typically result in a financial recovery, The 2010 2011NIHB Annual Report identifies the total amount of audit recoveries.
including Next Day Claims Verification NDCV and Client Confirmation Program. CCP savings from all components of the Express Scripts Canada Provider. Audit Program as 460 833 NDCV savings listed in the recovery charts for this. timeframe do not take into consideration the provider appeals process All claims. that are reversed prior to being paid to providers are deemed savings to the. Program Subsequent appeals to these reversals may lead to claims being paid. in full to providers once appropriate billing and supporting documentation has. been provided for review, During the 2010 2011 NIHB fiscal year nineteen pharmacy audits were. conducted in Manitoba resulting in total recoveries of 152 579 Detailed. information about audit findings can be found in Section 9 2 Audit Activities in the. NIHB Annual Report at, http www msp mb ca PDF 3rdParty NIHB 20Annual 20Report 202010. MSP was able to obtain the statistical breakdown of audit recoveries within. Manitoba between April 1 2011 and March 31 2012, Initial Audit Recoveries by Reclaim Code in Manitoba. April 1 2011 to March 31 2012,Recovery Description Number of Percentage. Code claims in error,11 Incorrect Billing Pricing 15 407 46.
21 Unauthorized Rx Refill 7 355 22,20 Original Rx or Hard Copy Refill Not 2 757 8. Found On Site,8 Incorrect Person 2 192 7,25 Other 1 498 5. 22 Incorrect DIN Drug Or MS E Item 896 3,4 Incorrect Professional Fee 1 522 5. Unauthorized Prescription Splitting,18 Filled Too Soon No Documentation 339 1. 10 Item s Not Covered 493 1,23 Physician ID Issue 185 1.
5 C O B Issue 94 0,3 Incorrect Quantity Days Supply 342 1. Please see Appendix A Audit Findings and Recovery Activities for a. detailed description of each recovery code, To help clarify the audit process the Manitoba Society of Pharmacists MSP has. developed the NIHB Pharmacy Audit Toolkit The Toolkit is intended to support. assist and prepare MSP member pharmacists with the audit of NIHB beneficiary. prescriptions by, Highlighting key points within the NIHB Pharmacy Claims. Submission Kit the Express Scripts Pharmacy Provider Agreement. and the NIHB Pharmacy Guide for Pharmacy Benefits, Reviewing prescriptions for validity as required by pharmacy. practice standards in the province of Manitoba,Suggesting audit prevention measures.
Providing an audit preparation checklist, Including relevant websites and documents dedicated to NIHB audit. recovery prevention, This document will focus on on site audits Members are strongly advised to. become familiar with Appendix B NIHB Pharmacy Claims Submission Kit. Section 8 specifically page 27 30 Provider Audit as well as Appendix C. Express Scripts Pharmacy Provider Agreement Section 6 Claims Audit for. pharmacy contract information and Appendix D Audit Findings and Recovery. Actions NIHB Pharmacy Provider Audit Program for explicit requirements of. the program,ROLE OF MSP, MSP has regular communications with NIHB on behalf of all Manitoba. pharmacists for economic and professional services Included in that role is. communications with NIHB representatives regarding audit activity within the. province MSP has had direct consultation with NIHB representatives to develop. and finalize the contents of this document In the process MSP has been. assured that program expectations are consistent with provincial pharmacy. legislation with exceptions being explicitly defined in NIHB program policy. Many instances of audit concerns expressed by pharmacists during the research. for this document appear to be historical in nature NIHB has assured MSP that. audit activities have been changed or updated to reflect provincial requirements. and Program policy, If for some reason audit activity is not consistent with provincial pharmacy. legislation NIHB has requested to be notified of specific examples Therefore. member pharmacists are encouraged to contact the MSP office at. info msp mb ca or 204 956 6681 if they,have received notification of a pending audit.
have questions or concerns about audit activity or. notice inconsistencies between provincial pharmacy legislation and. audit activities that are not explicitly defined in NIHB program. MSP will provide guidance and will continue to support member pharmacists by. advocating for a transparent audit process that will not compromise patient safety. and will help prevent audit recovery,NON INSURED HEALTH BENEFITS AUDIT. PROGRAM OVERVIEW, The Non Insured Health Benefits Program of the First Nations and Inuit Health. Branch FNIHB Health Canada provides health benefits to registered Indians. eligible Inuit and Innu individuals in Canada Express Scripts Canada ESC is. the claims administrator for the NIHB Program previously First Canadian. As a publicly funded program Health Canada is required to account for. expenditures The Agreement signed by the manager of each pharmacy allows. ESC to audit paid prescription claims within the terms and conditions of the NIHB. program The time period of audit coverage is at the discretion of ESC but on. average is a sample of the last two years or as long as the prescription is being. dispensed if no end date to refills Further information can be found in Annex D. on Page 21 of the Express Scripts Canada Pharmacy Provider Agreement. All audit activities such as the selection of pharmacies audit process and. reported findings are reviewed and approved by representatives of Health. There are five components of the Pharmacy Provider Audit Program These are. 1 Next Day Claims Verification NDCV Program which consists of a review. of a defined sample of claims submitted by providers the day following. receipt by FCH ESC, 2 Client Confirmation Program CCP which consists of a monthly mail out. to a randomly selected sample of NIHB clients to confirm the receipt of the. benefit that has been billed on their behalf, 3 Provider Profiling Program which consists of a review of the billings of all. providers against selected criteria and the determination of the most. appropriate follow up activity if concerns are identified. 4 On Site Audit Program which consists of the selection of a sample of. claims for administrative validation with a provider s records through an. on site visit and, 5 Desk Audit Program which consists of the selection of a sample of claims.
for administrative validation with a provider s records Unlike on site. audits a desk audit serves to validate records through the use of fax or. mail Generally a smaller number of claims are reviewed during a desk. GENERAL AUDIT RECOVERY PREVENTION, To help prevent audit recovery community pharmacies are encouraged to. develop and implement policy and procedures that meet Express Scripts. Pharmacy Provider Agreement requirements, MSP suggests annual or more frequent reviews of the following documents and. websites as part of policy and procedures development. Website or document,o NIHB Drug Pharmacy Website,o NIHB Provider Guide for Pharmacy Benefits. o NIHB Pharmacy Claims Submission Kit,o NIHB Pharmacy Claims Submission Kit. Attachments,o Express Scripts Canada includes NIHB.
newsletters in sign in area,o Pharmacy Provider Agreement. o The Pharmaceutical Act Assented to July 26 1991,o Audit Findings and Recovery Activities CPhA. PROVIDER INFORMATION CHANGES, Express Scripts Canada must be notified immediately upon change of any. provider information including but not limited to dispensing fee changes usual. and customary fee charged to cash paying customers The Modification to. Pharmacy and Medical Supplies and Equipment Provider Information Form at. http www provider express, scripts ca pdf Pharmacy English Modification to Pharmacy and MSE Provider. Information Form pdf should be completed in hard copy by the provider and. forwarded via e mail or fax to Express Scripts Canada Forms can also be. obtained by contacting the Provider Claims Processing Call Centre directly at 1. 888 511 4666 for a copy, This form should be used to update any of the following.
Dispensing fee change usual and customary fee charged to cash. paying customers, Type of communication preferred by pharmacy provider from NIHB. i e Fax mail etc, Operating name change only when Legal Name and Ownership. Names remains the same see below, Initiation change or elimination of Electronic Funds Transfer. Providers wishing to change Legal Name and or Ownership Names must contact. NIHB and complete a new Pharmacy Provider Agreement whereby a new. Provider ID number will be assigned,COORDINATION OF BENEFITS. As a reminder Non Insured Health Benefits NIHB Program clients that have. alternate health coverage are required to access that coverage prior to claiming. NIHB Program benefits As of July 16 2012 the NIHB Program has put in place. administrative measures to ensure the coordination of benefits with third party. insurers Please note that pharmacy providers will now be required to submit. reimbursement claims to the alternate health coverage prior to billing the NIHB. Program The Program will then coordinate payment with the other payer on. eligible benefits, The intent of this notice is for pharmacists to make NIHB the payer of last resort.
Only when a claim is not accepted by other coverage should it be submitted to. NIHB Pharmacists are also instructed to note on each prescription claimed. through NIHB that an attempt was made first to submit it to another provider. As a result of these changes please ensure that the status of insurance. coverage of each patient is frequently updated, In the event that a third party payer rejects a claim with the explanation that. coverage is only provided for NIHB clients if the product required is not covered. through the NIHB program the pharmacy is expected to maintain the notification. of rejection of the claim on file to avoid future audit When possible a. screenshot of the private plan rejection should be printed and attached to the. prescription, See Appendix E Coordination of Benefits Bulletin for detailed information. COMPONENTS OF A PRESCRIPTION, NIHB audits pharmacy providers to ensure program policy is adhered to. Program policy states that providers must retain a copy of the original. prescription on file for two years or as long as it is being dispensed against if. longer than two years in accordance with provincial or territorial requirements. The Non Insured Health Benefits Program of the Pharmacy and Medical Supplies and Equipment Provider Information Form at Only when a claim is not accepted by

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