Pharmacies often need to adjust the quantity being dispensed from what was originally prescribed. While there are a multitude of reasons these changes might be necessary, the rationale may be closely scrutinized during an audit. Auditors will look for documentation to justify any deviation from the originally prescribed quantity; missing (or inadequate) documentation can lead […]
Pharmacies know Ozempic® prescriptions have been on PBM radars since they were first released. Not only are these high dollar claims, but they are an easy target for incorrect billing. Making a simple days’ supply error on an Ozempic® claim can result in thousands of dollars being recouped.
Retail pharmacies exploring the option to provide long-term care pharmacy services at home must be aware of additional requirements that apply. In 2005, CMS provided guidance to Part D plans on requirements for performance and service criteria regarding pharmacies servicing LTC facilities. More recently, this guidance has been applicable to pharmacies servicing LTC Pharmacy at […]
OptumRx continues to focus on medications with special dispensing requirements. Creon® has ranked among the top five medications requested through OptumRx prescription validation requests for the past three years and that trend is continuing into 2026. Although the PBM characterizes these reviews as prescription validation requests rather than desk audits, PAAS National®® analysts consistently see […]
Pharmacies face audit risks in their everyday operations, and staying ahead to protect claims from audit recoupments can be exhausting. PAAS National®® analysts continue … Interested in a customized FWA/HIPAA Compliance Policy and Procedure program? Contact PAAS National®® at info@paasnational.com or (608) 873-1342 to get started today!
Last month we wrote an article entitled: Guidelines for Dispensing Insulin Pens in their Original Carton. A few days later, the Office of Inspector General (OIG) announced that CVS had agreed to a $37.76 million settlement for violations of the False Claims Act by over-dispensing insulin pens between 2010 and 2020. Investigators found that Medicare, […]
Keeping up with all the new insulin products has become a full-time job. The range of delivery devices and concentrations continues to expand. Pharmacies need to stay informed about these updates to ensure their prescriptions meet audit requirements. Recently, PBMs have flagged insulin prescriptions as …
Pharmacies serve a vital role in supporting their communities, especially when patients face disruptions during natural disasters. In such events, access to essential medication can be compromised. While helping patients through these challenging times, ensure that your pharmacy’s claims remain protected by confirming staff understand which override(s) to use and how to apply them correctly.
Transferring prescriptions into your pharmacy is usually great for business; however, pharmacies must be aware of the additional audit risks with these prescriptions. PBM audit algorithms easily identify transfers due to the origin code of 5 being submitted during claim adjudication. Each state has requirements put in place by their pharmacy board that outline what […]
While the COVID-19 Public Health Emergency officially ended on May 11, 2023, the 12th Amendment of the Public Readiness and Emergency Preparedness Act (PREP) was extended until December 31, 2029. This allows pharmacies to continue dispensing OTC COVID-19 tests to patients without a prescription. Many state Medicaid and commercial insurance plans continue to cover this […]
