PAAS National®® has noticed an uptick in audit recoupments for Suboxone® claims where the patient instructions were to split the films or tablets. Notably, OptumRx has a renewed focused on these claims and has been citing them as…
According to 21 CFR 1306.03, a prescriber must be authorized to prescribe controlled substances in the place they are licensed to practice and must either be registered with the DEA or exempted from registration (typically reserved for officials of the U.S. Army, Navy, Marine Corps, Air Force, Space Force, Coast Guard, Public Health Service, or […]
While the day-to-day operations of an LTC pharmacy may be drastically different from retail pharmacies, auditors frequently treat them the same, especially when it comes to documentation requirements.
A recent audit trend shows that some major PBMs are challenging the perceived legitimacy of patient signatures. In particular…
A Corrective Action Plan (CAP) is a document your pharmacy may develop in response to issues that arise (e.g., negative audit findings), helping to identify root causes, and how your pharmacy will prevent the same discrepancies from happening in the future. You may choose to develop your own informal CAP to help train or retrain […]
Calculating the days’ supply on a claim is something every pharmacy does throughout the workday. With a multitude of claims, clerical errors are bound to happen. What are the audit consequences when a days’ supply is billed incorrectly?
PAAS National®® has recently seen an uptick in the number of unannounced CMS site visits related to Medicare enrollment or revalidation. These visits are currently being conducted by Novitas Solutions, the contracted National Provider Enrollment East (NPEast) contractor and Palmetto GBA® for the NPWest. Site visits are performed to verify the business location and ensure […]
With more pharmacies exploring the world of long-term care and LTC Pharmacy at Home dispensing increasing daily, PAAS National®® has also been seeing audits on these claims. One area PBMs have been targeting surrounds…
OptumRx continues to focus audits on prescriptions that must be dispensed in their original container per the manufacturer’s [FDA approved] labeling and package insert.
Oral inhaler prescriptions are frequently targeted for audit by PBMs because of their cost, frequent billing errors (e.g., incorrect days’ supply), or prescribing errors (e.g., non-mathematically calculable directions or incorrect written quantity). Vague written quantities can cause recoupments when multiple package sizes exist, including institutional package sizes.
