Managed Care Pharmacy Claims Paid to ReCept Pharmacy #1
Learn how the AI-generated research projects were createdOverall Conclusion
ReCept Pharmacy #1 properly billed for paid claims and complied with applicable contractual, Texas Administrative Code, and federal requirements for most claims tested; however, ReCept did not consistently comply with requirements for accurate claims submissions and dispensing labels.
Source Document
Audit Scope
The audit scope covered the period from September 1, 2020, through August 31, 2021.
Key Findings Summary
Administrative errors in claims submission: two claims with errors—one with zero authorized refills when two were authorized; one with an incorrect dispense as written (DAW) code.
Dispensing label errors: for 20 of 60 claims, the dispensing label listed remaining refills that did not align with the prescription’s total remaining refills, primarily involving injectable pen medications.
AI-Assisted
AI Scope Summary
This audit evaluated whether ReCept properly billed Medicaid/CHIP claims and complied with contractual, state, and federal requirements for the September 1, 2020–August 31, 2021 period, finding general compliance but specific deficiencies in refills, DAW coding, and dispensing-label accuracy that should be addressed to improve controls in future audits.
AI-Generated Insight
The audit found that while most claims were accurately billed, notable control gaps exist in claims submission (refill counts and DAW coding) and dispensing label accuracy for injectable pens. These gaps suggest a need for stronger data validation, staff training, and IT-system enhancements to prevent refill miscalculations and incorrect labeling.
Audit Objectives
Determine whether ReCept properly billed for paid claims associated with Medicaid and CHIP members enrolled with Aetna Better Health of Texas, Inc.
Determine whether ReCept complied with applicable contractual, state, and federal requirements.
Audit Findings (2)
Administrative errors in claims submission: two claims with errors—one with zero authorized refills when two were authorized; one with an incorrect dispense as written (DAW) code.
Dispensing label errors: for 20 of 60 claims, the dispensing label listed remaining refills that did not align with the prescription’s total remaining refills, primarily involving injectable pen medications.
Recommendations (2)
Continue to ensure accurate submission of the correct number of authorized refills and the correct DAW code for each claim in accordance with contractual and Texas Administrative Code requirements.
Ensure the number of authorized refills remaining on the dispensing label is accurate prior to dispensing medications.