Background

Under the terms of the Community Pharmacy Contractor (CPC) Agreement with the HSE, pharmacies providing services on behalf of the State are obligated to comply with all regulations as outlined in the agreement. Compliance with the agreement is overseen by the Primary Care Reimbursement Service (PCRS) and its officers.

The IPU’s Pharmacy Contractors Committee agreed with the PCRS to introduce the owings functionality to guarantee full transparency and compliance of claims submitted, and as a result remove any probity issue in relation to owings for the contractors. All contractors were instructed to activate this owings functionality as outlined within the HSE Circular 030/22.

Efficient claim management is paramount to avoid the occurrence of rejected claims. It is imperative to establish precise processes and adhere to the provided PCRS rules to ensure proper claiming procedures. Implementing appropriate guidelines right from the start is of utmost importance. The process of resolving rejected claims can be intricate and time-consuming. The complexity increases when dealing with rejected claims that involve outstanding owings.

The recently introduced owings functionality serves as a valuable tool for pharmacists, as it prevents the dispensing of a new item if there are any unresolved owings linked to the same item. Owings functionality will also stop you from claiming a non-dispensing fee for any item where that item has an outstanding owing for a patient.

When claiming remember that:

• Owing functionality only applies to GMS, GMR, dental, hospital emergency and EU schemes;
• There is a system issue that prevents you from discharging an owing within a minute timeframe of initially placing an item as an owing;
• You should only discharge the owing when stock is available and where you have a reasonable expectation that the patient will collect their owing;
• You must submit an initial owing reimbursement claim to receive reimbursement for subsequently discharged owings of the same item; and
• You should ensure careful verification of owing claims in your claim file before transmission to the PCRS for payment.

Verifying your claim file when you have an outstanding owing in your dispensing system

The initial owing item, whether it is a standalone item or included with other items under the same form number, will present in its regular format for verification purposes. All subsequent discharges of owings of this item will maintain the consistent form numbers (256/09) as shown in the example below. This enables a traceable connection between each owing with the original dispensing and allows for effective payment reconciliation.

Table 1: Owing example

As you verify your claims, you will notice that owing transactions appear on multiple lines. A line will be visible for the initial owing and a separate line for each subsequent dispensing of this owing.

In such situations, the initial owing should be verified and submitted with your monthly claim file, while any subsequent owing will be dispensed either within the same claim period, or a future one.

All parts of the form number require verification, as failure to verify even one part can result in the claim being declined. Even if the initial owings has a zero-cost value, ensuring that this has been claimed is important to avoid rejection.

How to prevent rejected claims

• A defined process should be in place for managing owings to ensure patient safety is maintained, and it should provide details on both dispensed and uncollected medications by patients;
• If the supply of the owing takes place within the same day or the same reimbursement month, verify all electronic claims for this owing before submission to ensure accurate payment;
• Running an owings report regularly will facilitate the reduction of the level of owings; and
• Perform your IPU monthly product file update at the start of the month to prevent claiming discontinued codes.

Reclaiming related rejects associated with owings

The first step in any reject management process in a pharmacy is to ensure that you are downloading your exception file, fixing, and then resubmitting within the specified time frame. The next step is to ensure that you download the final exception file and fix any rejects electronically; these reject claims will be included in the next month’s claim file.

Ignoring a reject will impact any future dispensing related to that item. All future claims with a discharged owing for the same patient will also be rejected until the reject claim which had the original owing is rectified and resubmitted to PCRS with the monthly electronic file.

Be careful prior to discharging any owing to ensure that you have the medicine, and the patient requires the medicine. Reintroducing owings to the Patient Medical Record (PMR) once they have been dispensed is not permitted and will cause a reject. A consistent error message indicating the owings error will be displayed for all rejected owings and will appear in the itemised claims listing.

Conclusion

Timely reimbursement for dispensed medications is contingent upon correct claiming and verifying. Correct payment for prescriptions where owings have arisen requires clear processes to be adhered to within your pharmacy. While addressing these complexities can prove challenging, having a proactive process and rectifying outstanding owings will prevent potential future rejects. We strongly advise implementing appropriate measures to manage the owings process in your pharmacy to mitigate any costly repercussions, as resubmitting claims can be a burdensome and time-consuming task.

The IPU Contract Unit is here to help you. Contact Zrinka Bulj or Linda Ahern, Claims Analysts on 01 406 1557 or 01 493 6401, or email contract@ipu.ie.

Legacy owings

Do not delete your legacy owings — these are owings registered on your PMR prior to the introduction of the owings functionality: this record represents medicines for which your pharmacy has received reimbursement from the PCRS. It is important to generate and review your owings report. Should you have any inquiries or concerns regarding the reimbursed items, please reach out to the IPU Contract Unit. We are here to provide guidance and support in navigating the Pharmacy Contract process with the HSE.