PAAS National® frequently sees claims audited that contain a clinical drug utilization review (DUR) or submission clarification code (SCC), particularly from Express Scripts and Prime Therapeutics.
Auditors target pancreatic enzyme prescriptions like Creon® and Zenpep® due to high cost and ambiguous directions.
The Public Health Emergency for COVID-19 ended on May 11, 2023, and PBMs notified pharmacies that they would once again be requiring signatures for proof of patient receipt of medications.
Many pharmacies use an automatic refill process to streamline the labor needed to fill prescriptions.
It is that time of year again; flu shot season is upon us. As busy as this season can be, we know you do not want to worry if you have all the documentation you need in case of an audit.
There has been some discussion in pharmacy circles about clinical notes and whether PBMs are requiring them to be electronically annotated (or if hand-written clinical notes will continue to suffice).
We have all been there – a prescriber calls the pharmacy to find out which prescription from a therapeutic category will be the most cost-effective for the patient.
Humana has recently sent out another round of audits where either an incorrect NDC number or National Provider Identifier (NPI) was billed.
How many times have you received a prescription for a bowel prep, starter pack, or pre-packaged taper where the directions simply state, “Use as Directed?”
GLP-1 medications being used off-label for weight loss, and the corresponding audit risk, has been a hot topic for awhile now, but there are other medications that PAAS National® frequently sees recoupments for when being used off-label, especially when billed to a Medicare plan.
