Govt cracking down on PBS claims, prescriptions

female pharmacist prescription script dispensary

Pharmacist claims are reportedly under review as the government queries pharmacies on flagged scripts and warns of potential future audits if concerns are identified

The Department of Health Compliance team is currently conducting a review of PBS claiming, focusing on multiple payments for identical PBS items, according to a Guild member alert.

The Pharmacy Guild says that 289 pharmacies have received a letter asking them to review some flagged prescriptions and to fill in a voluntary acknowledgement form if they find that they have claimed PBS items incorrectly.

As this review is not an audit, the pharmacists who have received letters are not required to send any response to the Department.

However a pharmacy owner who received one of the letters has told AJP that it was never mentioned that it was not audited.

“We got one of these letters six months ago, based on some nursing home patients who had changed pharmacy as we didn’t renew the contract,” says the source, who prefers to remain unnamed.

“We didn’t receive our last set of scripts for a while, and when we finally did, it was too long for some owings to be reclaimed.

“The correct procedure is to delete and reprocess, which makes it look like they were never supplied until today,” they said.

“Problem is, that overlapped with the new pharmacy dispensing (as it would) so we were asked to repay the claim.

“We felt that we were not in a position to challenge it. It was never mentioned that it was un-audited.”

The Guild says that if after checking the relevant claims and being satisfied there is no claim issue, a pharmacist may opt to email with their reference number and acknowledge that they have reviewed their claims as outlined in the schedule they received and believe they are compliant.

“If a pharmacist has reviewed their claims and has identified that some claims are not correct, then the voluntary acknowledgement form sent with the letter should be completed and returned as requested,” says the Guild.

“If the pharmacist has a specific query relating to prescriptions that have been flagged for review and would like further advice before completing the voluntary acknowledgement form, then they should email the Compliance Team and include:

  • The name of their pharmacy,
  • The reference number on the letter,
  • The nature of their enquiry – especially if they have a specific query,
  • Any other relevant details.”

Currently it is taking 5-10 working days for the Compliance Team to respond to emails and they have requested that pharmacies do not send multiple emails as this will slow the process.

The Department has advised the Guild that the response deadline has been extended from 15 February to 1 March 2019.

While the compliance exercise is reportedly entirely voluntary, the Department of Health signals it will continue to monitor PBS claims into the future and may take compliance action – such as an audit – if concerns are identified that an approved supplier has not met the PBS requirements and has been paid pharmaceutical benefit payments they were not entitled to receive, according to the Guild Alert.

“If this occurs, administrative penalties may be applied and debt recovery action will be taken. Members should ensure dispensary staff assess and respond to any warnings provided through PBS Online,” says the Guild.

The Department has also highlighted that it is pharmacists’ responsibility to ensure that they dispense and supply pharmaceutical benefits in accordance with the relevant legislation, and an approved pharmacist must not supply a pharmaceutical benefit to a person unless the prescription is written in accordance with the National Health Act 1953 and National Health (Pharmaceutical Benefits) Regulations 2017.

“If two prescriptions are written on the same day for the same item for the same patient, one is a valid PBS prescription and the other may only be supplied as a private item to a patient,” reads the alert.

The Department of Health has also advised it is considering education activities to alert prescribers to their obligations when writing PBS prescriptions.

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