PAAS National®® analysts regularly assist pharmacies that need to perform a Root Cause Analysis and/or Corrective Action Plan (CAP) due to high dollar audit recoupments or other major discrepancies (e.g., inventory shortages). These significant results can trigger further consequences such as additional audits, payment suspension and/or the threat of network termination. CAPs are intended to […]
As PBMs audits continue to evolve and aggressively pursue recoupments, PAAS National®® continues to see audits that scrutinize beyond general prescription information. When preparing the documentation requested in an audit, it is important to review more than what is on the face of the hard copy and prescription label. DUR (Drug Utilization Review) override documentation […]
PAAS National®® audit analysts have the privilege of assisting pharmacies in all 50 states, DC, Puerto Rico and the Virgin Islands. With the DOJ expanding Health Care Fraud units, pharmacies should expect increased monitoring on Medicare and Medicaid programs targeting FWA, state law violations and program compliance. If you haven’t…
Last month, PAAS National®® wrote about the record-setting $6.8 billion in False Claims Act recoveries in fiscal year 2025. With a continued and expanding focus on fraud enforcement, and strong recoveries in the health care and life sciences, expect an increase in cases the Department of Justice is investigating. In a recent case, two individuals […]
Many pharmacies are familiar with Prolia® (denosumab) for the treatment of osteoporosis in women after menopause who are high risk for fracture or cannot use another osteoporosis medication (or the other medications weren’t efficacious). There is another denosumab product (brand name Xgeva®) approved for bone problems due to cancer. Prolia® and Xgeva® are not …
Partially dispensing prescriptions is a common, and practical, approach used in pharmacy practice to ensure patients receive timely access to medications when the full prescribed quantity is not immediately available. Rather than delaying therapy, a pharmacy may dispense a portion of the medication and provide the remaining balance at a later time. Partial dispensing most […]
The first year of the Medicare Payment Prescription Plan (M3P) is over and there was a learning curve for pharmacies and patients alike. It took time for pharmacies to understand the program and what was expected. Along with that, PAAS National®® saw new communications from PBMs regarding M3P noncompliance. Around May of last year, OptumRx […]
Pharmacies have sent PAAS National®® notices from Caremark entitled “CVS Caremark Rx Claim Review.” The first line of the notice says, “This communication is for educational purposes only and is not part of an audit.” This has led to many questions and confusion amongst the pharmacies receiving these notices. PAAS has seen waves of these […]
Analysts at PAAS National®® assist with invoice audits on a daily basis. While not as common (in number) as desk audits, the implications of bad audit results are high and can be challenging to appeal. Often questions come up asking why it matters if the exact NDC is billed? A few recent cases from the […]
For independent pharmacies, invoice audits continue to gain traction by the PBMs. While the recently announced WAC decreases make bulk purchasing a potentially precarious scenario, one PBMs also has rigid requirements for “bulk purchasing”.
