An Easy Procedural Change That Will Prevent Recoupments

As previously reported in an April 2023 Newsline article, Prepare Yourselves! Onsite Audits Are Coming in Strong, PAAS National® saw a 300% increase in onsite audits in just the 3rd Quarter of 2022, and we have continued to see the number of audits, as well as the information requested in these audits, increase. It is therefore pertinent that pharmacies review and enforce their FWA/HIPAA policies and procedures, such as return to stock, to prevent petty recoupments.

Return to Stock, the timeframe PBMs require prescriptions to be picked up or the claim reversed based on the fill date of a prescription, is a focus of onsite audits when the auditor inspects the Will Call bin or desk audits when a signature log is requested. If the auditor identifies the sold/received date is beyond the PBM’s Return to Stock threshold, there is risk for full recoupment of the claim.

When determining what Return to Stock window is appropriate for your pharmacy, consider the following: 

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!

  • Each PBM’s Return to Stock window varies. How many days from the date of the adjudicated claim does the patient have to pick up the prescription before it is returned to stock? Is that number of days based on calendar days or business days?
  • When is your pharmacy filling prescriptions relative to when the prescription is being delivered to long-term care facilities, mailed to patients, or sent out for delivery?
  • What processes are in place to contact the patient when they have a prescription ready to be picked up? Does the patient receive a text message or phone call that a prescription is ready for pick-up? Do you contact the patient after a certain number of days to check if they still need the prescription?
  • What processes are in place depending on the type of prescription? Do you put all bowel preparation or post-procedure prescriptions on hold until they are requested?
  • Review PAAS’ Return to Stock chart, located on the PAAS Member Portal under Days’ Supply Charts, which includes the Return to Stock policies for major PBMs. For other PBMs that you serve and are not listed on our chart, refer to the respective PBM Provider Manual.

All above information should be considered when reviewing your pharmacy’s FWA/HIPAA policy and procedure manual (Section 4.1.1 Unclaimed Prescriptions for those utilizing PAAS’ FWA/HIPAA Compliance program). Make modifications as seen fit.

Lastly, see if your pharmacy system can help stop prescriptions that would be sold beyond your designated Return To Stock window. Certain dispensing platforms, with an integrated Point of Sale system, can have claims stopped at the register to avoid noncompliance.

PAAS Tips:

  • In order to be adherent to the vast majority of PBMs, PAAS suggests considering a 7-10 calendar days return to stock policy for your pharmacy
  • Contact software vendors about providing daily reports that reflect which claims have not yet been picked up and are approaching your Return to Stock window
  • Prior to an onsite audit, do an extra pass of your will call bin to ensure all prescriptions waiting to be picked up are within your Return to Stock window
  • REMS prescriptions may require specific restrictions for pick up, see our June 2021 Newsline, Would Your REMS Prescription Pass an Audit?
  • If a patient informs you that they will be picking up their prescription but it will be after your Return to Stock window, reverse and rebill the claim. Notating on the prescription that the patient was contacted and will be coming in at a later time will not suffice for PBM’s purposes
  • Partial/Completion, and LTC prescriptions are not exempt from Return to Stock policies
  • Do not have patients sign for prescriptions that were previously received as this is not an accurate reflection of the date the patient obtained the prescription
  • Refer to our March 2023 Newsline, PBM Trend That Never Changes? Return to Stock Policy Violations

Meredith Thiede, PharmD