Prescriptions transferred into your pharmacy, especially for high-cost medications, should be thoroughly reviewed for completeness, as missing or incomplete elements can quickly become a costly audit risk. Transferred prescriptions are common audit targets because origin code 5 makes them easy for auditors to identify, and auditors know these prescriptions require additional supporting documentation. Just one […]
The National Average Drug Acquisition Cost (NADAC) Survey has been around for over a decade, but some pharmacies have never received this survey request before. Consequently, PAAS National®® is frequently contacted for information and guidance.
There are numerous reasons why a Schedule II controlled substance (C-II) may be partially filled. Understanding the rationale behind the partial fill is necessary to ensure: (1) the authorization to partial fill is valid and (2) appropriate documentation is maintained pursuant to State and Federal Laws, such as 21 CFR 1306.13. There are three major […]
PBMs utilize many different strategies to evaluate the legitimacy of pharmacy claims. Desk, onsite, and invoice audits are traditionally performed, but sometimes auditors will expand their investigation outside of pharmacy-provided documents to further validate the claims. Occasionally, PBMs will send questionnaires to patients (and even prescribers) to confirm valid patient-prescriber-pharmacy relationships. These questionnaires are typically […]
Audits from CMS through the Supplemental Medical Review Contractor (SMRC) are rolling in at high volume for continuous glucose monitors (CGMs), HCPCS E2103. The goal of SMRC is to help lower improper payment rates by conducting nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claim to determine whether claims follow coverage, coding, payment, […]
Tetanus, Hepatitis A/B and Rabies vaccines may be covered by either Medicare Part B or Part D. Coverage typically depends on the vaccine’s purpose:
Estrace® and Premarin® vaginal creams continue to be audit targets because they are often found to be billed incorrectly. A recovery on one claim billed with a wrong days’ supply often causes subsequent refills to be recouped for being ‘refilled too soon’. To prevent this claim recoupment…
The most recent Office for Civil Rights (OCR) Cybersecurity Newsletter was released in January and focuses on system hardening and protecting electronic PHI (ePHI). “System hardening is the process of customizing electronic information systems (e.g., computer systems and other electronic devices) to reduce their attack surface, thus reducing the number of weaknesses and vulnerabilities that […]
CVS Caremark updates, and mails, their complete provider manual in a hardcopy version to member pharmacies every other year, on even years. Pharmacies should have received a printed copy of the 2026 Caremark Provider Manual towards the end of last year. Undoubtedly due to congressional pressure, and as discussed in this month’s feature Newsline article: […]
PAAS National®® continuously monitors legislative and regulatory changes that may impact your Fraud, Waste & Abuse and HIPAA Compliance Program. We keep a close eye on enforcement from the Department of Justice, Office of Inspector General, State Attorney Generals, and Office for Civil Rights to help ensure the program meets interpretative standards. Furthermore, PAAS works […]
