All Indiana Health Coverage Programs Pharmacy Providers. Most Common Billing Unit Discrepancies That Result in Manufacturer Drug Rebate Disputes

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1 Indiana Hlth Coverage Programs P R O V I D E R B U L L E T I N B T F E B R U A R Y 1 0, To: Subject: All Indiana Hlth Coverage Programs Pharmacy Providers Note: The information in this bulletin is not directed to those providers rendering services in the riskbased managed care (RBMC) delivery system. Overview For any drug manufacturer s products (both legend and over-thecounter) to be covered by the Traditional Medicaid Program the manufacturer must have entered into and have in effect a rebate agreement with the federal government. The essence of the agreement is that the manufacturer agrees to pay ch state, on a quarterly basis, a portion of the money that the state expended for that manufacturer s individual products. This process is based on the number of units of ch drug the state submits to the manufacturer for rebates. It is critically important that Traditional Medicaid Program providers submit the correct number of units on ch claim. The grtest number of manufacturer disputes is attributed to the number of units the state charges to the manufacturer. Some drug products have billable units that are obvious, for example, tablets or capsules are billed as ch. Other products, however injectable products, in particular do not have obvious correct billing units. IndianaAIM has built-in claims processing logic edits that were designed to identify potentially misbilled units Even with such edits, some products have had a large number of manufacturer rebate disputes. The purpose of this bulletin and others that will follow on a periodic basis is to highlight products that analysis has shown to cause manufacturer disputes because of potentially misbilled units. EDS 1

2 Indiana Hlth Coverage Programs Plse be aware that incorrectly billed units cause unnecessary administrative time and resources on the part of both the state and rebating drug manufactures and slows down the return to the state of the rebate-related proceeds. Also, manufacturers do retain the right to require audits of specific providers billing records, in the event of unresolved disputes. Careful adherence to correct billing of units will ensure that this is not required. According to records, Tables 1.1 and 1.2 relate those products most commonly disputed by rebating manufacturers. Table 1.2 lists the correct unit definition for drugs with substantial dispute activity. Definitions Plse be aware that there are only three, acceptable billing units for purposes of the Traditional Medicaid Program. They are as follows: Each () The billing unit for capsules, tablets, kits, and unreconstituted vials. Milliliters () The billing unit for liquid dosage form having a uniform concentration. Grams () The billing unit for products that are packaged by weight, such as ointments, crms, and powders that are not reconstitutable for injection. Factors Most Commonly Associated with Rebate-Related Disputes Analysis consistently revls the following factors as the most common causes of rebate disputes: Incorrect billing unit such as, using the number of milliliters in a vial as opposed to ch to specify the entire contents of the vial Note: This example is for illustrative purposes only. Some products are billed by and some by ch vial. Provider data entry errors, including those involving decimal or fractional quantities Units billed exceeding what would be expected as being within a normal range for the product for example, the billed units appr inconsistent with what is normally dispensed quantity would be EDS 2

3 Indiana Hlth Coverage Programs Charge amounts that suggest a generic might have been dispensed when a brand name National Drug Code (NDC) was submitted on the claim Providers are encouraged to contact the Indiana POS/ Pro-DUR Help Desk at if in the course of billing the Traditional Medicaid Program for dispensed drugs, there is a question on what constitutes the correct unit for that drug. All efforts to help minimize the number of manufacturer disputes are appreciated. Plse compare current billing practices to the indicated billing unit in the following tables to ensure consistency. Table 1.1 s for Commonly Billed Products Drug Product Oral Antibiotic Suspensions All Oral Inhalers Ointments and Crms Ativan Tubex Syringes Rdy-To-Use IV Antibiotic Minibags Metamucil and Psyllium-like Products (Jar) Metamucil and Psyllium-like Products (Packet) Birth Control Pills Glucagon F 1 mg Emergency Kit Rocephin 10 Vial Norplant System (tablet) (kit) (kit) Table 1.2 contains a list of specific drug products and the correct billing unit. 2% Xylocaine Viscous Solution Acetic Acid 5% Solution Aerobid M Adapter Albuterol.83 mg/ Solution Albuterol 5 mg/ Solution Albuterol Sulfate 2 mg/5 Syrup Amicar Syrup 25% EDS 3

4 Indiana Hlth Coverage Programs Amoxicillin 125 mg/5 Suspension Amoxicillin 250 mg/5 Suspension Ampicillin 250 mg/5 Suspension Anusol Ointment Anusol Suppository Artificial Trs Drops Ativan 2 mg/ Tubex Syringe Ativan 2 mg/ Vial Atropine 1% Eye Drops Azmacort Inhaler Bacitracin 500U/ Ointment Bacteriostatic Water Vial Betamethasone DP.05% Ointment Betamethasone VA.1% Ointment Bisocodyl 10 mg Suppository Catapres-TTS Patch Cefaclor Suspension Cleocin Phosphate 150 mg/ Vial Clindamycin Ph 1% Solution Cliquinil Powder Clobetasol.05% Crm DDAVP 0.01 Solution DDAVP 4 mcg/ Ampule DDAVP INJ 4 mcg/ Vial Depo-Provera 100 mcg/ Vial Dermabase Crm Desmopressin 0.1 mg/ Solution Desmopressin AC 4 mcg/ Vial Dexamethasone.5 mg/5 Elixir Dobutamine 500 mg/d5w 250 Duragesic 100 mcg/hr Patch Efudex 5% Crm EDS 4

5 Indiana Hlth Coverage Programs Erythromycin Estolate 250 mg/5 Suspension Estradiol Powder FEIBA VH Immuno U Vial Floxin IV 4 mg/ Mini Bag Fluocinolone.01% Solution Fluocinolone.025% Crm Fluocinonide 0.05% Ointment Fortaz ADD-Vantage Vial Furosemide 10 mg/ Oral Solution Gammagard S/O.5 Gentamicin 0.1% Crm Gentamicin 0.1% Ointment Gentamicin 40 mg/ Sryringe Gevabron-Liquid Glucagon F 1 mg Emergency Kit Gyne-Lotrimin 7 Day 100 mg Heparin Sodium 10 mu/ Vial Herceptin 440 mg Vial Humalog Humulin R 500 U/ Vial Hydrocortisone 1% Crm Hydrocortisone 2.5% Crm Hydrocortisone Powder Hydrocrm Base Iletin II Pork Lente 100U/ Imitrex 6 mg/.5 Syringe Kit Infergen 15 mcg/0.5 Vial Insulin N Beef 100U/ Vial Intal Inhaler Intron A 6 mmu/ Vial Keflex 250 mg/5 Oral Suspension Ketoprofen 75 mg Cap EDS 5

6 Indiana Hlth Coverage Programs Ketoprofen Crystalline Powder Lactulose 10 /15 Syrup Leucovorin Calcium 350 mg Vial Libirum 100 mg Ampule Lidex Crm.05% Lorabind 100 mg/5 Suspension Lorazepam.5 mg Tab M.V.I. 12 Combo Package Maalox Suspension Major Trs Drops Major Trs Eye Ointment Meperidine 25 mg/ Tubex Metamucil Powder Metamucil Packet Metoclopramide 5 mg/5 Syrup Monistat-7 Crm Mycelex-7 1% Crm Mycelex mg Vaginal Tab Mylanta Liquid NasalCrom 4% Neupogen 300 mcg/ Vial Norplant System Kit Nordette-28 Norinyl Tab Norinyl Tab Novolin 70/30 Novolin N 100U/ Cartridge Novoseven 1200 mcg Vial Novoseven 4800 mcg Vial Nystatin U Powder Nystatin Crm100000U/ Omnicef 125 mg/5 Suspension EDS 6

7 Indiana Hlth Coverage Programs Opticrom 4% Eye Drops Ora-Sweet SF Syrup Ortho-Diaph.65 Ortho-Diaph.70 Ortho-Diaph.75 Ortho-Diaph.80 Ortho-Diaphra Allflex 85 mm Pediapred 6.7 mg/5 Solution Penicillin VK 125 mg/5 Liquid Phenergan 25 mg/ Ampule Phenergan 25 mg/ Tubex Syringe Phenobarbital 20 mg/5 Elixir Phospholine Iodide.25% Pilocarpine 4% Eye Drops Poly-Vi-Sol Potassium Chloride 10% Liquid Premarin Vaginal Crm Refill Premarin Vaginal Crm w/applicator Prochlorpoerazine 5 mg/ Vial Progesterone Powder Micronized Promethazine 25 mg/ Ampule Promethazine 50 mg/ Ampule Promethazine 6.25 mg/5 syrup Promethazine VC Syrup Promethazine w/codeine Syrup Propine.1% Eye Drops Pulmozyme 1 mg/ Ampule Recombinate AHFU Vial Robinul.2 mg/ Vial Sandostatin.2 mg/ Vial Silver Sulfadiazine 1% Crm Sodium Bicarbonate 8.4% Vial EDS 7

8 Indiana Hlth Coverage Programs Sodium Chloride 0.9% Ampule Sulfamethoxazole w/tmp Ssuspension Sulfamide 10% Eye Drops Synvisc-Syringe Tazidime 2 Vial Testosterone Powder Testosterone Propionate Powder Theophylline 80 mg/15 Elixir Thera Liquid Tilade Inhaler Timentin 3.1 /100 RTU Timoptic.5% Eye Drops Torecan 5 mg/ Ampule Transderm-Nitro.8 mg/hr Transderm-Scop 1.5 mg/72 hr Tri-Norinyl 21 Tab Tri-Norinyl 28 Tab Tussionex Pennkinetic Suspension Ty-Pap w/codeine Elixir Valisone.01% Crm Valproic Acid 250 mg/5 mg Syrup Vancocin HCl 1 Solution Vasolate-HC Ear Drops Ventolin 90 Inhaler Vivelle.1 mg Patch Vivelle.075 mg Patch Xalatan 0.005% Zosyn 3/0.375G Pre-Mix Bag Zosyn 4/0.5G Pre-Mix Bag EDS 8