MPA Works to Correct Faulty Methodology Used in Part D Project Audit

Early in the summer, many pharmacies in Missouri received self-audit letters from the Missouri Department of Socials Services (MDSS) MMAC unit pertaining to the Part D project of MO HealthNet pharmacies. These letters asked pharmacies to perform tedious self-audits on what MMAC believed were overpayments from the state program to the pharmacy and send payment for the overage to the state.

Upon notification of these letters being received by members, MPA immediately contacted the MMAC unit for more information. An error was discovered in the methodology being used by MMAC to process this information. MMAC is currently processing refunds for all pharmacies that responded to the self-audit with payment.

A re-analysis of the data and methodology used in the project is explained below along with the amended methodology, and is an excerpt from the letter being sent with refunds:

“The original methodology included pharmacy claims from eMOMED and corresponding Medicare Prescription Drug Events from an extract of Missouri data. The identification of a Health Insurance Claim (HIC) number indicated the recipient was also a Medicare beneficiary. The claims were then matched for the same dispensing date (date of prescription fill), HIC number and NDC. Claims below $5 were excluded as they represented legitimate copays made by MO HealthNet as well as claims for benzodiazepines, barbiturates, and over-the-counter medications. All other claims were then regarded as duplicate payments. However, in order for the above methodology to be accurate, it must take into account all relevant state policies related to payment of pharmacy claims by MO HealthNet.

CMS has now amended the original methodology. The amended methodology takes into consideration MMAC’s request to further examine the data using Medicaid eligibility (ME) codes 82, 11, 13 and 15. MMAC asked CMS to exclude from review participants who: (a) are enrolled via the Missouri state buy-in program; (b) are elderly, blind and disabled individuals who meet the Medical Assistance eligibility criteria in the community or a vendor facility; or (c) receive a Missouri State Supplemental Conversion or Supplemental Nursing Care check. It also appears an edit may have been put in place around 2010 which impacted the results of the original analysis. Missouri data does not include ME codes for years 2007-2009 and, as such, the amended methodology cannot be applied accurately to the 2007-2009 results. Therefore, MMAC will be processing refunds to the providers who responded to the self-audit letters relating to the years 2007-2009.

Further analysis for years 2010-2012 is still being conducted and determination of payment errors will be forthcoming. MMAC apologizes for any inconvenience this may have caused you. We are very appreciative of the input of pharmacy providers and the Missouri Pharmacy Association in helping us resolve this matter.”

The leadership of MPA appreciated the opportunity to work with MMAC to address this issue. We will be working with them to monitor future programs and will try to eliminate any unnecessary audits.

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