PAAS National® is seeing a rising number of Caremark® audits requesting proof of copay collection. This requested information may be included in a desk, virtual onsite, or invoice audit. The number of claims requested can range from just a few claims to all dates of fill for several prescriptions.
Transferred prescriptions remain a common audit target, and pharmacies are facing recoupments due to missing information.
Pharmacies know the importance of billing accurate days’ supply on prescriptions; however, there may be circumstances that can make this challenging.
Dispensing medications outside of FDA packaging requirements may put your claims at risk of recoupment. Medications sensitive to light and/or moisture may require pharmacies to dispense the medication in the original container.
PAAS National® has recently received several FWA audit results requiring the pharmacy to submit additional, and arduous, supporting documentation. Pharmacies need to be aware of the audit risks for medications with high Average Wholesale Prices (AWP) and narrow FDA approved indications (e.g., Pennsaid®). Significant time and effort must be put forth by the pharmacy, prescriber and potentially the patient, to support these claims.
PAAS National® continues to see pharmacies losing money due to violating PBM Return to Stock policies. Each PBM sets a timeframe that unclaimed prescriptions must be reversed and returned to stock. Full recoupment of the claim can occur when a PBM discovers prescriptions are dispensed to patients outside this timeframe. Staying up to date on Return to Stock requirements is imperative.
The United States Department of Justice recently released the outcome of an investigation of the False Claims Act. Two pharmacists and their management company in Pennsylvania agreed to pay $250,000 to resolve the potential liability.
PAAS National® continuously keeps close tabs on legislative and regulatory changes that may impact our members’ Fraud, Waste & Abuse and HIPAA Compliance Program.
June delivered a bombshell for over 300 pharmacies when Express Scripts recouped payment for TRICARE prescriptions dating back to 2015. These recoupments occurred before pharmacies were even notified, leaving many struggling to make payroll and pay wholesalers – in the middle of a Pandemic.
