Humira (adalimumab) is a monoclonal antibody designed to block tumor necrosis factor-alpha (TNF-α), a protein involved in systemic inflammation. It was approved by the FDA in December of 2002 for treating rheumatoid arthritis and was the first fully human monoclonal antibody approved for therapeutic use. Over time, Humira gained additional approvals for the treatment of […]
Claims for Zepbound and other GLP-1 receptor agonists are commonly targeted by auditors. The high claim value paired with their numerous pitfalls make them ‘easy pickings’ for PBMs. Billing a wrong quantity, days’ supply or formulation can put your claims at risk. To make things even more complex, Zepbound has multiple formulations with varying volumes, […]
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 […]
