Nayzilam is indicated for the acute treatment of intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient’s usual seizure pattern (for patients 12 years of age and older), while Valtoco has the same indication for patients 2 years of age and older. They are frequent audit targets…
PAAS National®® continues to review audits for Shingrix, a vaccine indicated for prevention of herpes zoster (shingles) in adults over 50 years of age (and certain immunosuppressed adults over 19). These audits appear to have been triggered by…
PAAS National®® continues to see audits for alcohol swabs. While billing for alcohol swabs often seems trivial, there can be confusion when these claims may be covered under the Medicare Part D or Medicare Part B benefit. Claim recoupments stemming from billing to the wrong benefit are common. Alcohol swabs are only covered under Part […]
The practice of Pharmacy is governed by many statutes, regulations, and laws that pharmacy owners and employees must navigate every day. One such law is the Federal Anti-Kickback Statute (AKS), 42 U.S.C. 1320a-7b(b). This law protects federally funded health care programs (and patients) and provides criminal sanctions for those who knowingly and willingly offer, pay, […]
PAAS National®® has seen invoice audits double in the last five years, a trend that has sparked widespread discussion from community pharmacy owners. Invoice audits are frequently categorized as “investigational” and used to identify pharmacies not purchasing from appropriate sources and/or potentially false (or phantom) claims. Auditors will act like an accountant by reviewing the […]
PBM contracts require pharmacies to obtain evidence that demonstrates prescriptions were received by patients, ensuring claims are not falsely submitted for reimbursement. In community pharmacies, a patient typically signs a log when picking up their medication at the pharmacy (or upon delivery). What happens if the prescription is mailed to the patient?
According to the FDA labeling, isotretinoin capsules are indicated for the treatment of severe recalcitrant nodular acne in non-pregnant patients 12 years of age and older with multiple inflammatory nodules with a diameter of 5 mm or greater.
Several audit discrepancies can be resolved by obtaining a letter from the prescriber clarifying their intentions for a prescription they wrote. While PAAS National®® often gets requests for a template/form letter, this is problematic and impractical (except for Humana). PBMs have their own requirements and no two prescribers would write their letters using the same […]
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 […]
