Long Acting Reversible Contraceptive (LARC) and Depo-Provera® (medroxyprogesterone) Claims Review Program

Tuesday, November 10, 2020

During a recent medical and pharmacy claims analysis, billing anomalies for Long Acting Reversible Contraceptives (LARCs) and Depo-Provera (medroxyprogesterone) claims were identified. The anomalies identified fall into the following categories: 

  • Duplicate paid claims 
  • Non-compliance to the 340B billing policy  

As a result of these findings, NC Medicaid has contracted with Myers and Stauffer, LC to conduct an ongoing claims review to identify and take actions on LARC and Depo-Provera overpayments.  

  • Myers and Stauffer, LC will contact providers regarding the identified claims in question.  
  • When contacted, providers will be asked to confirm the billing parameters for the claim(s) in question.  
  • If it is determined that the claim was billed incorrectly or in error, providers will be asked to correct the claim(s) and resubmit or reverse the claim(s).  
  • If claims are not corrected, then Myers and Stauffer will submit the claims to NC Medicaid/Fiscal Agent to recover the overpayments.

It is important for providers to discuss correct billing procedures with their staff and billing contractors to ensure that the claim is submitted accurately and in compliance with NC Medicaid policies. In addition, it may be helpful to provide staff and billing contractors with job aids associated with common billing codes for the insertion and removal of LARCs and administration of Depo-Provera (medroxyprogesterone). The information below describes the above anomalies in further detail and provides useful links for providers to NC Medicaid policies and publications. 

Duplicate Paid Claims

NC Medicaid allows claims for LARCs and Depo-Provera (medroxyprogesterone) to be submitted through either the outpatient pharmacy benefit or medical benefit. Outpatient pharmacy claims for LARCs and Depo-Provera (medroxyprogesterone) typically originate from specialty pharmacies that have received a prescription from the medical provider.  

Most often, the specialty pharmacy will submit the claim for payment and subsequently ship the drug product to the medical provider’s office/clinic for insertion. However, the specialty pharmacy may ship the drug product directly to the beneficiary or a beneficiary could potentially pick their prescription up from a local pharmacy and take it with them to the medical provider’s office/clinic for administration.  

When the medical provider is inserting a LARC or administering Depo-Provera (medroxyprogesterone) that they have received from the pharmacy, or that the beneficiary has brought in for insertion/administration, the medical provider should not bill the HCPCS code associated with the actual drug product because the medical provider did not purchase the drug that is being inserted/administered.

  • In these cases, medical providers should only bill for the insertion/administration of the drug. 
  • Paid claims were considered potential duplicates if they were billed and paid through the outpatient pharmacy benefit and subsequently paid through the medical benefit for the same beneficiary within one month of each other, based on the date of service on the claim.  .

Please reference the following links for more information on LARC and Depo-Provera (medroxyprogesterone) billing policies:

Non-Compliance to the 340B Billing Policy

NC Medicaid and Health Choice Physician’s Drug Program Clinical Coverage Policy No. 1B states that “For 340B drugs, provider(s) shall bill the cost that is reflective of their acquisition cost. Provider(s) shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.” 

Drugs purchased through the 340B program should be purchased at or below the 340B ceiling price and the billed amount should reflect this price. Paid claims submitted with a “UD” modifier were considered potentially out of compliance with the 340B billing policy when the submitted and paid amount exceeded the estimated 340B ceiling price.  

NC Medicaid would like to remind all 340B providers that 340B claims submitted through the medical benefit should contain a “UD” modifier; for the purpose of this project, claims without a “UD” modifier were omitted.  The Health Resources and Services Administration (HRSA) requires all 340B providers to have mechanisms in place to prevent duplicate discounts. NC Medicaid utilizes the “UD” modifier to exclude claims from the rebate invoicing process. Errors in billing 340B claims may result in penalties to 340B covered entities.  

Please reference the following links for more information on 340B billing policies and procedures:

Contact

NCTracks Contact Center, (800) 688-6696