In their effort to reduce medical expenditure, the HSE has brought in additional administrative barriers to phased dispensing. They were communicated to the pharmacists in the Circular 013/17 on 10 April 2017, which is reproduced below (our emphasis).
These validation arrangements for submitting phased dispensing claims came into effect on 1st May 2017. Previous correspondence of 5th May 2016 continues to apply.
There are a number of reasons previously agreed as appropriate for claiming phased dispensing fees.
- At the request of a patient's physician;
- Due to the inherent nature of a medicinal product i.e. product stability and shelf life;
- Where a patient is commencing new drug therapy with a view to establishing patient tolerance and acceptability before continuing on a full treatment regime;
- In exceptional circumstances where the patient is incapable of safely and effectively managing the medication regimen.
As a result of the increase in phased dispensing claims in recent years, the HSE, with the agreement of the Department of Health, believes it is necessary to introduce an approval mechanism for prior authorisation before reimbursement claims for phased dispensing under Reasons 1 and 4 can be submitted in future by a pharmacy for a named patient.
Thus, from 1st May 2017, prior approval for phased dispensing claims will be necessary for all newly initiated phased dispensing patients for subsequent reimbursement claims to be paid.
There will be no change to the existing arrangements where a phased dispensing service is required under Reasons 2 and 3, which are very occasional and specific in nature. The rate of such claims will continue to be monitored and can be added to the new arrangements if necessary.
On the PCRS Pharmacy Application Suite, from 1 May 2017, pharmacies will find Phased Dispensing Approval Request screens for completion. For phased dispensing fees to be payable in respect of newly initiated patients, Pharmacy users must first enter a valid Medical Card Number and identify either Reason 1 or Reason 4 as the reason that the patient requires a phased dispensing service. This must be done prior to providing a phased dispensing service to the patient.
Where the GP has made a request to the dispensing pharmacy by inserting the words "phased dispensing" on the face of the prescription, Reason 1 should be chosen, with a copy of the GP prescription displaying the doctor's instruction for phased dispensing scanned or photographed and attached on the application suite before submission.
In exceptional circumstances where the patient is incapable of safely and effectively managing their medication regimen, it remains available for the Pharmacist to make that determination as a sole practitioner. However, in those circumstances where the Pharmacist has assessed the patient risk and made the determination that exceptional circumstances apply, Reason 4 must be chosen. Where the following criteria can be confirmed, it is highly likely that the patient will be approved in a very short timeframe:
- Patient is over 80 years
- Patient is on one or more psychotropic medicines (with the 5 digit codes of the relevant medicines provided)
- Patient is on 5 or more oral medicines in a month.
- PSI Registration of Pharmacist conducting the assessment
- Date of Pharmacist assessment of patient
If one or more of the above confirmations cannot be provided, the application will require further assessment and it may be 24 hours (Monday to Friday, or the first working day after a weekend) before approval or non-approval will be communicated back to the pharmacy by the PCRS through the application suite. While the application is under consideration, "pending" will be displayed on the screen.
Similar functionality will be made available to GPs if they wish to enroll patients for phased dispensing services without writing "phased dispensing" on the face of the prescription. Where a GP completes the application, it will be automatically approved and contemporaneously visible on the Pharmacy application suite for that patient as Approved.
If an application for a phased dispensing service is Not Approved, and the Pharmacist wishes to appeal the HSE decision in this regard, an appeal can be registered by the pharmacist by providing additional information on the patient's particular circumstances to the HSE Pharmacist in whose operational area of responsibility the pharmacy is located. The quickest mechanism for approval in these circumstances would be where the patient's GP also believes that the patient cannot safely and effectively manage their medication regimen, in which circumstance, if the GP submits the patient's Medical Card Number a phased dispensing service will be automatically approved.
Claims in respect of patients who have previously been and still are in receipt of phased dispensing will continue to be honoured for the immediate future. However, after a period of adjustment during the implementation phase, these existing claims will be subject to review. In rotation, pharmacies whose reimbursement claims for phased dispensing are under review during that month will be informed in the first week of the month. Once notified, the pharmacies must submit relevant information on their existing patients for whom they provide a phased dispensing service for HSE consideration for continued approval. Pharmacies will be given notice where it is the HSE determination that a phased dispensing service is not necessary and incurring avoidable expense for the HSE. The appeal mechanisms as outlined above will apply.
Phased Dispensing on Other Schemes
By express statutory provision, phased dispensing has been confined to the GMS Scheme by the Health Professionals (Reduction of Payments to Community Pharmacy Contractors) Regulations 2009 (Statutory Instrument revoked) and the Health Professionals (Reductions of Payments to Community Pharmacy Contractors) Regulations 2011 (Statutory Instrument revoked).
Currently, by a similarly-worded provision contained in the Health Professionals (Reduction of Payments to Community Pharmacy Contractors) Regulations, 2013, it states:
Schedule 2: Other amounts payable under the General Medical Services Scheme Reference
Number (1) Phased dispensing fee payable per drug item for each dispensing phase other than the first dispensing phase (for which the standard dispensing fee specified in Schedule 1 is payable)
It is always open to the Pharmacy to use professional judgement in relation to supplying the patient under any Scheme. However, unless and until there is a change in policy by the Department of Health, phased dispensing can only be remunerated under the GMS Scheme.
Patients Residing in Nursing Homes
You are reminded that where nursing supervision is available in a patient's residential setting, phased dispensing claims should not be submitted but in any event, will not be reimbursed. (Ref. Circular 19/07)
Some claims are presented as four separate prescriptions each for one week's supply. It remains our position that such attempted circumvention of the HSE's previously stated policy regarding nursing home patients is not acceptable for reimbursement.
I trust that this clarifies the matters arising in this growing area of expenditure for the HSE and look forward to your cooperation in this regard.
ENDS