Empowering Pharmacy Teams to Decrease Audit Risk

Sir Francis Bacon is often credited with stating “scientia potentia est” in his published work, Meditationes Sacrae from 1597. This Latin phrase roughly translates to “knowledge is power” and while this turn of phrase is centuries old, it holds true today. The pharmacy industry is an ever-changing world and staying up to date on audit trends, safe billing and filling tips and unique issues in the independent pharmacy world goes beyond empowering staff. Knowledgeable staff can decrease a pharmacy’s overall audit risk and decrease potential audit recoupments when the claims they bill, fill, verify, and dispense are being done “by the book”, or more accurately, “by the PBM Provider Manual”.

It would be unrealistic to assign every pharmacy employee the task of reviewing and comprehending everything found within all PBM Provider Manuals. In and of itself, the 2025 OptumRx® Third Edition Version 3.1 Provider Manual is over 180 pages! However, it is essential for every pharmacy owner and operator to be familiar with the contents of each Provider Manual, as these manuals are considered an extension of the contract agreed upon when enrolling in the network. Failure to comply with the requirements outlined in the Provider Manual can significantly increase audit risk and lead to dire consequences in the event of an audit.

This is where PAAS National® can assist! The PAAS analyst team routinely monitors CMS and third-party payor requirements and alerts our members to relevant information. This is done through numerous avenues including the monthly Newsline articles, days’ supply charts, and other filling and billing guidance documents. However, these tools and resources are only helpful if staff are aware of their existence, have easy access to them, and stay informed about updates.

Have no fear—giving employees access to the wealth of knowledge PAAS has to offer can be accomplished in a matter of minutes! One of the pharmacy’s designated administrators or officers (as indicated in the Portal), can add new employees by:

  1. Logging in to the Portal
  2. Clicking on the blue audit assistance box
  3. Then, in the gray column of options down the left side of the screen, clicking the “Employees” button
  4. From there, click the green “+Add Employee” button in the upper right corner of the screen
  5. Finally, enter the employees’ information

By default, each employee entered will receive the monthly eNewsline delivered directly to their email inbox, have access to the Portal to view current and archived Newsline articles, view pharmacy tools and aids, and have the ability to ask filling and billing questions. Additionally, Portal access will allow them to view on-demand webinars regarding a variety of topics and even upload audit documents for the PAAS team to review.

With ever-changing PBM requirements, evolving audit targets, and high staff turnover, staying up to date on the details essential for minimizing audit risk can be a constant challenge. Let PAAS help lighten the load. Ensure all employees are entered into the Portal so they can access the valuable industry guidance we have to share. After all, knowledge is power.

PAAS Tips:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Join today!

Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.

  • Access Services
    • Audit Documentation Submission Guidance
    • An online form to submit safe filling and billing questions
    • Your PAAS Membership Manual
  • Newsline
    • Monthly newsletter articles, written by our expert PAAS analyst team, provide safe filling and billing tips and relays relevant/current PBM trends to be help prevent audits
    • Search the Newsline Archive to get PAAS tips at the click of a button
    • Special Edition Newslines including: Top 10 articles of the prior year, DMEPOS Article Series and a Self-Audit Article Series
    • Ability to print monthly issues or individual articles
  • Proactive Tips
    • Audit flags – list of various claim attributes the PBMs use to select claims for audit
    • Billing insulin vials – flowchart to assist whether you should bill Medicare Part B vs Part D
    • DAW Codes Explained – use to understand when to effectively use DAW codes, their definitions and why claims may be flagged for audit if a DAW code is used incorrectly
    • Basic DMEPOS documentation guidance
    • Onsite Credentialing Checklist and expanded definitions of policies and procedures
    • Proof of refill request and affirmative response form for DMEPOS items
    • Steps on how to prepare for an onsite audit
    • And more!
  • Days’ Supply Charts
    • Utilize the days’ supply charts for inhalers, insulins, nasal sprays, eye drops and topicals to aid you in calculating the correct days’ supply
    • Guidance on overbilled quantities and incorrect days’ supply account for a sizable portion of audit chargebacks
    • Additional miscellaneous charts, which include: Dispense in Original Container and Return to Stock
  • Forms
    • Signature Logbook for print
    • Signature Trifold Mailer
    • Fax and Email Coversheet
    • Patient Attestation for over-the-counter COVID-19 test kits
  • On-Demand Webinars
    • Short webinars on hot topics in the PBM industry. Here are a few examples:
      • USP 800 Compliance
      • Cultural Competency Training
      • Dispensing Prescriptions Off-Label
      • Biologic Medications and Interchangeability
      • Continuous Glucose Monitor Requirements for Medicare Part B

PAAS Tips:

  • MORE AUDITS, MORE INSIGHT – PAAS National® is the industry-leading defender of community pharmacy dealings with Prescription Benefit Programs, including Caremark, Express Scripts, Humana, Medicaid, OptumRx, Prime Therapeutics., and more. PAAS assists on all third-party audits, including: desktop audits, onsite audits, invoice audits, OIG/Medicaid audits, Medicare B audits. The PAAS team is dedicated to helping you! We have five pharmacists and a complement of technician analysts with over 50 years of dedicated audit assistance experience. PAAS continuously updates their database with every audit received — in fact, we even keep a scorecard on individual auditors.
  • Get answers to your questions on days’ supply calculations, drug substitutions, billing practices, required documentation, prior authorization requirements, record retention, and internal audit procedures – just to name a few. As a trusted partner, we will provide tailored guidance to help you proactively prevent audits. Remember, the prescription claims you submit today are the audits of the future.
  • Keep your employees engaged and help lower audit risk by adding all employees to the portal and giving them permission to access these tools, resources and eNewsline. For more information review September 2019 Newsline article, What Are You Waiting For? Make Sure ALL of Your Employees are Added to the PAAS Portal!
  • Contact PAAS at (608) 873-1342, if you would like a tour of your PAAS Member Portal, so you can reap all the benefits of your PAAS Audit Assistance. We appreciate you being a member.
Sara Hathaway, PharmD
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