Resolving existing or potential drug therapy problems (DTPs) is a key part of optimizing medication therapies. To keep the focus on successful resolution of DTP interventions and to prevent fraud, waste and abuse, Outcomes assigns each pharmacy to a Quality Assurance Zone.
Quality Assurance Zones review the last six months of MTM claim history to identify pharmacies with atypical claim activity. Zone calculations look at both the types of interventions completed and the pharmacy’s success rate. At least one-third of MTM claims should be successful resolutions to Comprehensive Medication Reviews (CMRs) and drug therapy problems (DTPs), including patient adherence consultations and prescriber consultations.
How do I know what zone my pharmacy is in?
Pharmacies with standard claim activity are in the Green Zone and will not see an alert message. Should your pharmacy fall below guidelines, an alert will appear on your pharmacy dashboard. The Yellow and Red Zones are an opportunity for us to help you learn to maximize your MTM opportunities, so you can help your pharmacy return to desired program guidelines.
The Yellow Zone is simply a warning that your pharmacy’s balance of claims is falling below guidelines. Claim history shows a disproportionate number of unsuccessful claims. Focus on successfully resolving patient adherence consultations, prescriber consultations and CMRs to return to the Green Zone.
The Red Zone restricts you from submitting some claim types to help your pharmacy return to program guidelines. While in the Red Zone, you may only submit successful patient adherence consultations, prescriber consultations and CMRs. Claims with results of Patient Refused, Prescriber Refused Recommendation and Unable to Reach Patient/Prescriber After 3 Attempts will not be accepted, nor will you be able to leave claims in progress. You may not submit claims for a New or Changed Prescription Therapy or New or Changed OTC Therapy.
My pharmacy is in the Yellow/Red Zone, what should I do?
Look for opportunities to successfully complete patient adherence consultations, prescriber consultations and Comprehensive Medication Reviews (CMRs).
- Review pending MTM claims that you can successfully resolve.
- Review your pharmacy’s MTM Opportunities queue for patients in need of a CMR or with pending TIPs.
As you work to resolve drug therapy problems, consider these recommendations for increasing your pharmacy’s successful interventions.
- Talk to patients about TIP opportunities while they are in the pharmacy.
- Put a sticker on the patient’s medication bag, so the technician and/or pharmacist knows to speak to the patient about the issue.
- Reassure your patient that you will communicate with the prescriber.
- Example: “I may suggest a change to your medication to you and your doctor—but it would only be a suggestion. You and your doctor will always make the final decision.”
- Give the patient/prescriber time to respond to voice or fax messages.
- Be sure to leave time between your three attempts for the patient or prescriber to respond. If you faxed a recommendation, try following up with a phone call.
- Remember, you have 7 days from your third attempt to submit a claim as Unable to o Reach Patient/Prescriber After 3 Attempts.
Quick Reference Guide
Best Practices to avoid the Yellow and Red Zones:
- Attempt to reach the patient/prescriber one more time before submitting the claim.
- Consider a different contact method:
- Try a phone call instead of a fax.
- Catch the patient in person at the pharmacy if phone calls aren’t successful.
