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National Audit’s High Cost Drug/Home Infusion Audit Program targets the following non-hospital facility settings
in order to identify overpayments:
• Specialty Pharmacies
• Home Infusion Providers
• Ambulatory Infusion Centers
• Physician Specialties (Oncology, Immune Disorders)
• Outpatient Clinics
The High Cost Drug/Home Infusion program focuses on the validation of the charges billed versus contractual terms
(Average Wholesale Price, Average Sales Price, Medicare Allowable, etc.), as payers can have difficulty
understanding these terms as well as administering them in their claims system.
The program verifies what was prescribed versus the actual drug received by the patient in addition to
verification of the following:
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A valid prescription is on file |
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The drug was administered to the patient |
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Proper dosage |
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Proper
quantity |
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Units and method of administration |
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Prior authorization validation |
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Medical necessity |
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Drug administration was provided in accordance with the
treatment plan |
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