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KeyScripts TrendWatch: the Effect of Miscoding on Drug Program Monitoring and Reporting

The effective monitoring and accurate reporting of key drug program metrics like drug spend, network utilization and third-party billing depends on numerous factors, but it begins with accurate bill coding. The ability of the payor – working cooperatively with their PBM – to determine when drugs have been inappropriately coded or charged during the billing process is therefore a vital aspect of any drug program evaluation.

Today, drugs are being prescribed and dispensed in widely varying settings by a broad range of practitioners – the result of which has been an increase in certain prescription drugs being incorporated into other charge categories. Primary examples KeyScripts has encountered include specialty drugs coded as DME, as well as surgical implants, procedures, injections and supplies billed using codes captured on pharmacy reports. In addition, when calculating network and out-of-network costs, physician-dispensed drugs may or may not be attributed as drug spend, as they can be included on standard medical billing forms, with their costs incorporated into other charges, ostensibly for reporting purposes. For these reasons, the standardization of the methodology by which drugs costs and network utilization – particularly for out-of-network charges – is critical in the reporting process, and therefore in determining the effectiveness of any workers’ compensation pharmacy program. Recognizing this trend, KeyScripts works closely with customers to examine and refine the basis for the items and billing codes included in their drug spend data, allowing the most accurate evaluation of their pharmacy programs – which should be a chief consideration for all workers’ compensation payors.

Have questions or comments regarding this topic? Call 866.446.2848 and ask to speak to a KeyScripts pharmacist, or email schitwood@keyscriptsllc.com.

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KeyScripts TrendWatch: New Legislation Moves Pennsylvania Forward in the Fight Against Opioid Epidemic

Just three months after President Obama’s signing of the Comprehensive Addiction Recovery Act, which established multi-faceted strategies to address America’s opioid epidemic, on November 2, 2016, Pennsylvania Governor Tom Wolf signed into law a bill package with a similar aim. Through various control mechanisms, the legislation focuses on limiting outpatient access to opioids and improving disposal channels for expired and unused prescription medications. The sweeping legislation also seeks to frame the future of opioid drug therapy; Pennsylvania’s medical school curriculums must begin instructing tomorrow’s physicians on safe prescribing and drug disposal, pain management guidelines, alternatives to opioid therapy, identifying patients at high risk for abuse and addiction, and managing patients with substance abuse disorders.

Other related bills signed by the governor, which go into effect in January 2017, limit opioid prescriptions written from emergency departments and urgent care centers to a seven-day supply. Pennsylvania’s Pescription Drug Monitoring Program (PDMP), commissioned in August 2016, also will be more extensively utilized by physicians and pharmacists; one newly signed bill requires physicians to review patient PDMP profiles with every opioid and benzodiazepine prescription, and pharmacists will be required to enter opioid information into the PDMP within 24 hours of fill, rather than the previous 72 hours. To improve drug disposal channels, the new laws allow Pennsylvania’s police stations, hospitals, nursing homes and licensed pharmacies to serve as drop locations for expired and left-over medications. And as soon as new regulatory forms are available, physicians will be limited to prescribing a maximum of seven days’ worth of opioids (per prescription) to pediatric patients.

Pennsylvania’s opioid epidemic has grown increasingly alarming over the last few years. In 2015 alone, 3,500 Pennsylvanians died from prescription opioid and heroin overdoses, and according to a recent national survey on drug use and health, nearly 68% of people ages 12 and up have obtained pain relievers for non-medical reasons from a friend or relative. Since taking office last year, Governor Wolf had made the fight against opioid abuse a top priority in his administration, and following the bill signing, he stated the new legislation is “only the beginning” of the battle against opioid abuse.

To aid in Governor Wolf’s efforts, KeyScripts’ President Ray Hoover was invited to share his experience and insights with state legislators at the governor’s panel discussion on opioid and heroin abuse in the Commonwealth. KeyScripts, meanwhile, continues to help its clients control fraud, waste and abuse relative to prescription opioids and other costly medications – like compound drugs – in the workers’ compensation market. We are available to answer any questions you may have regarding opioid and compound drug utilization, and, if you’re interested, review your company’s opioid tracking and management strategies. Just call  866.446.2848, and a KeyScripts account representative will assist you.