To enhance profitability, pharmacy owners and operators have frequently incorporated immunization services into their offerings. While vaccines tend to carry a lower audit risk, the higher the cost of the vaccine, the more likely it is to be audited. The audit risk also increases when core billing elements of the vaccine claim are adjudicated incorrectly.
Just 11 short months ago, PAAS National®® released the NEW Dispense As Written (DAW) Code Revealed Newsline article about DAW code value “A” (408-D8). DAW A was designed to be utilized on multi-payor claims when one payor required a multi-source brand (or reference biologic with an approved interchangeable biosimilar in the marketplace) and the other […]
Undoubtedly, a calculator can be found near every data entry and verification station throughout the prescription workflow line. This is, in part, due to PBM requirements that prescriptions have a mathematically calculable set of instructions. Consequently, pharmacies should strive to bill every claim with an appropriate quantity and days’ supply to prevent claim recoupment issues […]
According to a March 27, 2025 U.S. Department of Justice press release, Walgreens has agreed to pay over $2.8 million to settle allegations of overbilling Medicaid Programs in Massachusetts and Georgia. Allegedly, Walgreens was submitting a higher usual and customary (U&C) price on certain generic drugs billed to these Medicaid programs which caused Medicaid to pay more than they should have.
Matching all 11-digits of the NDC billed to the NDC dispensed is one critical step in ensuring the pharmacy has adequate records to support the appropriateness of every claim billed.
CeQur SimplicityTM is a meal-time insulin patch approved for use in adult patients (over the age of 21) with Type 2 Diabetes and can replace up to 12 meal-time insulin doses. The patch delivers rapid-acting insulin in 2-unit doses through a flexible cannula by depressing two buttons, one on each side of the patch. This […]
It is no secret that margins on prescription medications have declined dramatically over the last few decades. Independent pharmacy owners are well aware of their less-than-favorable Pharmacy Benefit Manager (PBM) contracts, and their propensity to routinely audit. After working day in and day out to take care of the patients in your communities, auditors swoop […]
Desk audits, onsite audits, invoice audits…and HIPAA compliance audits?! Unfortunately every community pharmacy has some familiarity with third party payor audits, and PAAS National®® audit analysts bring their expertise to guide members through the entire audit process, ensuring everything goes as smoothly as possible. But what about HIPAA compliance audits? With a potential surge in these […]
PAAS National®® analysts have walked many pharmacies through the ins and outs of invoice audits. During our consultations with members who have their results back, the question of “Why would my invoice not be accepted?” comes up regularly. The answer to this question is multifaceted and can take some investigative work to identify the root cause. […]
The 2022 Dobbs v. Jackson Women’s Health Organization ruling, which overturned Roe V. Wade, prompted modifications to the Privacy Rule (45 CFR Parts 160 and 164). The Biden-Harris administration, partially through President Biden’s Executive Order (EO) 14076, aimed to better protect information related to reproductive health care, to bolster patient-provider confidentiality, and promote trust between […]
