PAAS National® continues to see PBM audits increase as we get further out from the formal end of the COVID-19 Public Health Emergency. One disturbing trend is the number of invoice audits, particularly from Caremark.
PAAS National® analysts receive many questions on Ozempic® relating to concerns about off label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing.
PAAS National® analysts have recently seen an increase in desk audits for worker’s compensation claims, mostly performed by Script Care.
Most pharmacies have grown accustomed to desk audits and providing copies of prescriptions, signature logs, and even copay collection records to PBMs upon request. Additionally, many pharmacies can recount their most recent experience with an onsite auditor visiting their pharmacy and the numerous questions related to operations, policies & procedures, and credentialing. However, not as many pharmacies have experienced an invoice audit – the stakes are higher and honest mistakes can lead to very expensive lessons in the process.
PAAS National® analysts have recently seen many PBMs and audit contractors send communications, including audit letters, to network pharmacies via email instead of facsimile or postal mail.
PAAS National® analysts frequently see PBM audit results where auditors have flagged claims with ‘incorrect DAW code submitted’ – while these are often educational discrepancies, it is important to understand the implications of incorrect DAW code submission and develop a consistent process for pharmacy staff to follow.
For the second time in the last three years, numerous pharmacies have received, what PAAS National® would consider extortionary, letters from LifeScan.
Pharmacies continue to see a large number of prescriptions for GLP-1 medications like Ozempic and Mounjaro and have concerns about the risk of PBM audits and recoupments.
PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
