24-644m Stay in Compliance With Drug Utilization Review Requirements
Date: 07/01/24
Reduce fraud, misuse and abuse of prescription drugs
As a contracted provider, you are receiving this information to keep you informed of the Plan’s responsibilities for a drug utilization review program. Entities delegated to fill prescriptions for outpatient drugs (“applicable entities”) are also responsible for the requirements.
On Sept. 25, 2023, the California Department of Health Care Services (DHCS) released All Plan Letter (APL) 23-026, which supersedes APL 19-012. On Feb. 20, 2024, the DHCS released 23-026 (Revised). The information in this provider update reflects guidance in the revised APL and replaces provider update 23-1490m, released Dec. 26, 2024.
The Plan and applicable entities must comply with APL 23-026 (Revised) and operate a drug utilization review (DUR) program1 that complies with the Medicaid-related DUR provisions contained in section 1004 of the SUPPORT Act.
The Plan and applicable entities must:
1 Operate a DUR program.
2 Submit the following to the DHCS:
· Updated policies and procedures (P&Ps) that address each of the requirements detailed below.
· Annual DUR Report.
The Plan must review its contractually required P&Ps to determine if amendments are needed to comply with APL 23-026 (Revised).
Be aware of what’s required in the DUR program
Requirements include the key elements listed below.
Claims review requirements
· Concurrent utilization alerts: Describe the process for claims review (retrospective) that monitors when the member is concurrently prescribed opioids and benzodiazepines or opioids and antipsychotics. (This does not preclude the establishment of a prospective safety-edit system to provide additional information to patients and providers at the point-of-sale about concurrent utilization.) The Plan and applicable entities that are not capitated for antipsychotic drugs are provided claims data, including for antipsychotic medications. The Plan and applicable entities are expected to perform, retrospectively, regular care management activities, including a review of concurrent use of opioid and antipsychotic medications, and take action accordingly on issues of concern to them.
· What’s excluded from the program: Plan members who are receiving hospice or palliative care; receiving treatment for cancer; residents of a long-term care facility, a facility described in section 1905(d) of the Act, or of another facility for which frequently abused drugs are dispensed for residents through a contact with a single pharmacy; Plan members who are receiving opioid agonist medications for treatment of substance use disorder; or other individuals the state elects to treat as exempted from such requirements.
Monitor antipsychotic medications used for children
The Plan and applicable entities are required to have a process to monitor and manage appropriate use of all psychiatric drugs to include antipsychotics, mood stabilizers and anti-depressant medications for all children under age 18 and all foster children. Based on the DUR program monitoring findings, the DUR program must have a process to address and improve concerning findings.
Identify fraud, waste and abuse (FWA)
Describe the process for identifying and addressing fraud and abuse of controlled substances by Plan members, health care physicians and other providers who are prescribing drugs to Plan members, and pharmacies dispensing drugs to Plan members. Also describe the actions that will be taken based on issues identified through program-monitoring findings.
How to report FWA
If you obtain information that reasonably leads you to believe there has or may have been a violation of law or of the Plan’s Compliance program, you must promptly report and disclose your concerns to the Plan’s Compliance Department using the contact information below. A report may be made anonymously. All reports to the Compliance Department are treated as confidential to the greatest extent possible. You also must cooperate with the Compliance Department in any audit or investigation implemented by the Plan due to your report. The Plan prohibits any form of retaliatory conduct or action against any employee or person who reports any compliance violation or concern.
FWA hotline: 866-685-8664
E-mail: Special_Investigations_Unit@Centene.com
Background
Federal law2 requires each state to develop a DUR program that is targeted, in part, at reducing clinical abuse and misuse of prescription drugs covered under the state’s Medicaid program. The SUPPORT Act added measures to combat the opioid crisis in part by reducing opioid abuse and misuse by advancing treatment and recovery initiatives, improving prevention, protecting communities and bolstering efforts to fight deadly illicit synthetic drugs. There were several Medicaid-related DUR provisions contained within section 1004 of the SUPPORT Act with respect to fee-for-service and managed care organization pharmacy programs. These provisions established drug review and utilization standards to supplement existing requirements under federal law, in an effort to reduce opioid-related fraud, abuse and misuse. Implementation and review of these strategies was required effective October 1, 2019.
The Centers for Medicare & Medicaid Services issued an Informational Bulletin on August 5, 20193, providing states with detailed guidance on implementation of these specific new requirements. In addition, DHCS APL 19-012, Federal Drug Utilization Review Requirements Designed to Reduce Opioid-Related Fraud, Misuse and Abuse, describes the Plan’s responsibilities related to the implementation of the federal law. You can view APL 19-012 and APL 23-026 (Revised) at bit.ly/APLs-DHCS or by scanning the QR code on page 3.
Additional information
Relevant sections of Health Net’s provider operations manuals and the Behavioral Health Provider Operations Manual have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal at provider.healthnetcalifornia.com > Provider Library under Quick Links, or go directly to providerlibrary.healthnetcalifornia.com.
Providers are encouraged to access the provider portal online at provider.healthnetcalifornia.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800 675 6110. Behavioral health providers can call 844-966-0298.
1 The DUR program must comply with Medicaid-related DUR provisions contained in section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (H.R. 6, the SUPPORT Act, P.L. 115-271).
2 Section 1927(g) of the Social Security Act (the Act). Section 1927(g) of the Social Security Act (the Act) is available at: www.ssa.gov/OP_Home/ssact/title19/1927.htm.
3 The August 5, 2019, Informational Bulletin can be accessed at www.medicaid.gov/federal-policy-guidance/downloads/cib080519-1004.pdf.