There are numerous entities that may initiate and perform pharmacy audits. While the actual audit process does not vary significantly, there are a few important nuances to understand.
PAAS National® analysts occasionally field questions related to copay collection, particularly with respect to prescriptions for pharmacy employees and their families.
Health Information Technology vendors in the pharmacy industry utilize large drug compendia databases to manage electronic drug files so that electronic transactions are all “speaking the same language”.
PAAS National® analysts have seen numerous PBM audit results where pharmacies had recoupments related to patient or prescriber denials of medications. Pharmacies are able to appeal by obtaining signed statements to overturn the denials.
PAAS National® analysts have recently worked with multiple pharmacies that received Compound Contract Violation notices from Caremark stating that the pharmacy must cease and desist submitting claims for “complex compounds” and reverse claims provided on an attached list.
Numerous PBMs are conducting audits and asking for proof of copay collection.
Without question, vaccine claims are on the rise! Consider a few best practices to reduce your risk of audit recoupments.
Two oral products have received Emergency Use Authorization for the treatment of COVID-19 infection – PaxlovidTM (Pfizer) and Molnupiravir (Merck).
Pharmacies have recently reported receiving telephone calls from Caremark’s audit department regarding claims for AndroGel® (testosterone) pump (and generics) related to incorrect package size billed.
The U.S. Department of Justice issued a press release on September 30, 2021, outlining that a former public official accepted “gratuities” (aka gifts or kickbacks) in exchange for referring business to a specific outside vendor.
