Setting limits: What’s good for your waist may also be good for your (brown/white bagging) waste.
It’s a new year!
While packing my lunch these days, I find myself setting better limits. In an attempt to prevent waist expansion, I check off my limits:
- 30 grams carbohydrate from grains
- 20 from fruit
- a fat limit of 15 grams
My pharmacy geek mind wanders past my brown lunch bag asking, ‘Can this technique be applied to medical drug claim waste prevention as well?’
For more information on Fraud, Waste and Abuse (FWA) issues specific to professional drug claims click here to view our White Paper on FWA specific to professional drug claims.
Brown/White Bagging Defined
If you are unfamiliar with the slang brown bagging and white bagging as it applies to pharmacy, let me get you up to speed.
Brown bagging is used to describe a situation where a pharmacy supplies a drug to a patient. The patient then brings the drug to a medical office or outpatient clinic for administration.
White bagging occurs when a pharmacy sends the medication directly to a medical office or outpatient clinic. This occurs as fulfillment of a prescription for a specific patient. The patient then goes to the office or clinic for medication administration.
The difference between the two being where the medication is delivered. In each instance, the drug claim is submitted by the pharmacy, the administration services are billed by the office or clinic and each medication fulfillment is based on an executed prescription for a specific patient.
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Where is the waste?
Taking advantage of the strengths of each provider, these models optimize drug delivery while reducing cost. However, they present unique opportunities for waste. Consider the following “what if” situations, that could result in medication being billed by the pharmacy but never administered to a client.
- The Prescriber or client discontinues therapy.
- The client is lost to follow up.
- The client has an adverse event, targeted outcomes are not achieved or a mutation occurs requiring a change in therapy.
Other causes of waste unique to this model include:
- medication double billing by both the pharmacy and administrator
- lost opportunities for utilization of leftover medication available in multiple-dose vials
- missed dose optimization based on single-dose vial availability
As an example, during my hospital experience, if a weight or BSA based dose barely exceeded a single dose vial package the following would occur. The pharmacist would notify the Prescriber of drug form availability and inquire if the total dose limited to the full vial would be sufficient. In this way, waste was prevented by avoiding use of a small amount from a second vial while not compromising patient care. As an auditor, I noticed documentation often did not demonstrate this type of communication between pharmacy and Prescriber in the retail or specialty pharmacy setting.
Setting limits can help avoid waste
Due to the complexity and variability between plans and payers, there is often not a ‘one solution fits all’ approach to health care waste prevention and management. Methods for prevention and detection of waste will be plan specific based on
- provider network contracting
- payer limitations
- claim submission and processing requirements
Strong contracts with specialty pharmacies who are experts in these drug delivery models can often prevent waste from the above situations. In addition to clinical services, if addressed in the contracts, a strong specialty pharmacy can
- verify continuation of therapy with the client and/or Prescriber prior to shipment
- limit shipment quantities to one dose at a time
- discuss available drug forms and dosing with the Prescriber
However, not every plan can place limits on pharmacy networks. To limit waste exposure, claim edits may be utilized to limit the quantities or units paid to a single dose per date of service. Claims processed using the NCPDP standard may be limited through days supply edits. Claims submitted through professional claims using HCPCS codes can utilize edits based on either maximum dosing units or a maximum allowed amount which takes maximum dosing units and fee schedules into consideration.
Good luck with setting your limits this year. Let us know if we can help.
A primer on the utilization of MinMax data and it’s use in professional drug claims edits can be found here.