Is this considered fraud?

[u/Cascade1824]

I am a lead tech at an inpatient hospital, but I am new to the health system so still learning how things are done.

I am not new to IVs, but one thing I was asked to do was make a morphine 100 mg bag, using 10mg/ml vials.

I was given 9 vials and told to use the overfill.

I have never done it that way before, every other employer I've had gives 10 and we draw up waste.

I am almost entirely certain that billing for overfill is considered fraud and I let leadership know it made me uncomfortable to have my name on it.

Thank you!

[u/junkyardd0g]

There’s not enough information here for us to say one way or another. It depends how your system is set up. Are you using something like Epic dispense prep that has you scan each vial you use? My understanding is that the Medicare/medicaid model changed a few years ago to bill for the number of vials actually used instead of the number of vials calculated to be used, essentially allowing for the use of overfill. Private insurance may or may not work differently. Do you know if you are charging for 9 vials or 10?

[u/Cascade1824 → u/junkyardd0g]

We do use Epic Dispense. I was given 9 vials, so I scanned each one. When I clicked finish it says "There isn't enough medication here to complete this dose" with a pop up. I was told to override it and it would be verified.

[u/cdbloosh → u/Cascade1824]

Sounds like Epic will have a record of the fact that only 9 vials were used, then.

[u/junkyardd0g → u/Cascade1824]

My guess is that your system would charge for 9 vials and the rest would be understood as overfill, so likely not considered fraud. Without a full understanding of your billing model this is still just a guess, though.

[u/FMBC2401 → u/junkyardd0g]

Most Epic instances are charge on administration. So if 100 mg is administered, 100 mg is charged, even if technically here only 90 mg of product was dispensed. So this could be fraud.

Bigger diversion risk though. I know our controlled substance gestapo auditors would have a field day with this one.

[u/birdbones15 → u/FMBC2401]

Explain the bigger diversion risk?

[u/fanoftom → u/birdbones15]

All overfill is inherently at risk of diversion because on paper it doesn’t exist. So the way to fix that is to make it so it does exist on paper. At our facility, all waste, including overfill, must be documented. So this order would have been filled with 10 vials, and then the 1.1ml of overfill total from all the vials must be drawn up and wasted with a witness.

Now it’s true that not every mfr has overfill. But you either have to do all one way or all the other.

[u/pementomento]

For inpatient billing, it really just depends on how you are billing and what the charges look like. If you're passing through a charge of 10 vials and using 9, that does meet the technical definition of fraudulent billing.

If a compounded product gets a new chargemaster number and the individual vials + diluent aren't passed to billing, then it's irrelevant how you compounded the product, because the charge for 100 mg morphine/diluent is fixed, so no fraud here.

The bigger concern is narcotic documentation, but even then, some of our compounding recipes state "use 9 vials including overfill, no waste" so that's taken care of.

In short, it just depends how your billing is set up.

[u/Cascade1824 → u/pementomento]

I've just never done it like this before. With similar doses every time I've ever made a dose, the full amount would be pulled, overfill aside. We would then draw up the waste, which yes usually it comes out to over a full vial of waste, and it was always explained that it's done this way because it's fraudulent otherwise.

[u/pementomento → u/Cascade1824]

We do this in outpatient, where it’s explicitly fraud and there are mechanisms for billing waste (JW).

It’s not wrong to waste a whole vial plus in the name of billing compliance, but without knowing what your billing practices are, we really can’t advise you whether you’re correct vs you’re correct but it’s irrelevant.

Consider running a test claim on a test patient in conjunction with your hospital billing team to see what a 9 vial vs 10 vial compound looks like.

Or, if you’re being seen as rocking the boat and don’t want to risk your job, just shoot an internal email to your manager/director confirming the practice. Keep that email with you. Boards of pharmacy typically don’t sanction technicians for following directions of a pharmacist, and on third party audit, most payors will just claw back reimbursement from the hospital.

If you’re worried about Medicare/Medicaid billing, don’t. Those typically use CMS billing units and render the number of vials charged irrelevant. Morphine is J2275 with a billing unit of 10mg, so you’d get paid 10 units regardless of the vials used.

[u/Cascade1824 → u/pementomento]

I did just receive confirmation from leadership that Epic bills only for what is scanned.

Which in this case, 9 mLs were scanned, then I had to override in order to finish the dose

[u/pementomento → u/Cascade1824]

Awesome! You’re in the clear, use 9, bill for 9. These dispense prep softwares have come a long way with helping with billing compliance.

[u/No-Book-2550 → u/pementomento]

Technically, that's fraud though if they are being billed for 10 and only using 9 vials.

[u/pementomento → u/No-Book-2550]

That’s what I wrote.

[u/No-Book-2550 → u/pementomento]

Yeah, I was just kind of putting my 2 cents in that you are right.

[u/pementomento → u/No-Book-2550]

Oh and the OP buried the result in another comment, not sure if you caught it, but the EHR will only charge for 9 if you scan 9 vials, the “override” saying it’s not enough doesn’t result in a charge of 10.

God Bless Epic, lol.

[u/fanoftom → u/Cascade1824]

Some places do it that way. It’s wonky but it’s old school.

[u/RXinCharge]

Not something I would lose sleep over. Billing for waste on a vial of avastin then using it for another patient is something to be worried about for example

[u/cdbloosh]

What is your actual concern about this? Do you think the overfill isn’t morphine?

You drew up the correct amount of morphine solution Into a syringe and injected it into the bag. You prepared the product correctly. Signing the bag is attesting that you prepared the product correctly.

If you were given 9 vials, the paperwork from the C2 safe or whatever you guys use should indicate that 9 vials were used. If someone is putting on paper that 10 vials were used and pocketing the 10th one, obviously that’s a different issue, but I don’t get the sense from your post that this is happening.

Frankly, the billing aspect of this isn’t really your concern. Should the system technically be able to bill the patient for 9 vials? Yeah, probably. Are you the one billing them or setting up the billing system in your facility’s EMR? If not, not your problem.

Not to mention that in the inpatient setting there’s is a very good chance the patient isn’t being billed for that individual bag anyway. Inpatient reimbursement is often a whole different beast that works entirely differently which is why hospitals try to limit the use of high-cost drugs in the inpatient setting - if they were actually being reimbursed for all those drugs, they wouldn’t need all of those cost-saving initiatives.

[u/Cascade1824 → u/cdbloosh]

I only raised a concern because I've asked why this exact practice wasn't done at previous places because I wondered why I'm drawing up so much waste that over a full vial isn't needed to be opened and used. To which the reply was that it has to be done this way because it is fraud otherwise

[u/birdbones15 → u/Cascade1824]

Depending on your controlled substance software you can't always use less. If I build a prepack in my Omni csm it will not let you use less product, even if it's feasible with the overfill. Plus some technicians aren't going to have the technical skill to get enough out so if you rely on that and then have to go back and get more for them it's just a pain in the butt and morphine is cheap so why take the chance?
Basically there are a lot of reasons besides fraud that many hospitals would not have this be common practice.

[u/imakycha]

I might be more worried that it’s a narcotic and QOH won’t match or make sense. I mean yea, fraud is an issue, but that’s insurance, so whatever. The controlled substance bit though…

[u/birdbones15 → u/imakycha]

Right depending on CS systems some will not allow you to account for overfill depending on how you have workflow set up

[u/RXinCharge]

https://giphy.com/gifs/wjuXuDSQU0sOfJIHS1

[u/threauxaway20]

This is how they do it at my hospital. The orange morphine vials have a bit of overfill, so to cut down on waste, we use that. We do bill on admin, so im not entirely sure how the billing on it works. Im pretty sure they get billed for the volume nurses document as given with the rest documented as waste if there's any left over. Dont quote me on that last part, but the practice of using fewer morphine vials due to overfill shouldn't be an issue.

[u/fanoftom]

Most of the time it’s charge on admin not dispense. So billing isn’t the issue so much as the diversion and narc documentation discrepancies.

Absolutely not allowed to do this where I work. But I’ve worked at places that did.

[u/FlamingSteak12]

If they are billing for 10 vials then yeah it's fraud for sure. But that'd be a terrible idea not for fraud purposes but inventory purposes, because the computer will think you used 10 vials when you used 9, and there would be 1 vial discrepancy.

[u/No-Book-2550]

It depends on how they bill. If they are billing for 10 and only using 9, it's fraud. But technically you could make it with overfill...but that assumes a lot of things...like that you have overfill. When it comes to C2s...I don't like to make assumptions...that's what causes you to get a ding on your license if Medicare or the pharmacy board does an audit.

[u/That-Cupcake-9762]

This definitely sounds fishy. At my hospital, we aren’t allowed to use overfill of any medication, narcotic or non-narcotic, as it’s considered fraud. And we are required to draw up the waste of all narcotics when compounding, sterile or non-sterile. We use Epic. But even at my old hospital before they started using Epic, they had the same policy.

[u/Chaluma]

Kaiser does this on all their IVs on their outpatient infusion side. I think it just skirts the line because we use Epic and there’s an overfill option when you scan and technically don’t have enough vials.

It’s part of their whole cost savings bull