The U.S. Department of Justice (DOJ) has announced an expansion of its Health Care Fraud Unit. The New England Strike Force—formerly responsible for Maine, New Hampshire, and Vermont—now includes Massachusetts. With this change, there are nine Health Care Fraud Strike Force locations nationwide, covering many of the country’s largest metropolitan areas.
The Health Care Fraud Unit is a specialized division within the DOJ that investigates and prosecutes fraud involving federal health care programs such as Medicare, Medicaid, and TRICARE. Its core mission is to protect taxpayer dollars, ensure patient safety, and uphold the integrity of the health care system.
For pharmacies, this expansion underscores the government’s increasing focus on detecting and preventing fraud related to billing, controlled substances, and prescription claims. The unit collaborates closely with the Office of Inspector General (OIG), Drug Enforcement Administration (DEA), and Federal Bureau of Investigation (FBI) to identify and prosecute fraudulent activities—including schemes involving unnecessary prescriptions, false claims, and diversion of controlled substances.
The DOJ relies heavily on data analytics and advanced algorithms to detect emerging fraud patterns and pinpoint high-risk behaviors. This means pharmacy billing and dispensing data may be analyzed for irregular trends or red flags, particularly in cases involving opioids or other controlled medications.
Pharmacies can reduce their risk by maintaining robust compliance programs, conducting regular internal audits, and ensuring accurate documentation of all prescriptions and reimbursements. As the Health Care Fraud Unit’s reach expands, proactive compliance and vigilance will remain essential for all pharmacy professionals.
PAAS Tips:
- Make sure your pharmacy has implemented a robust FWA compliance program, including written policies and procedures, compliance training, employee code of conduct, conflict of interest and business ethics. Protect your pharmacy by enrolling in the PAAS National® FWA/HIPAA Compliance Program today.
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Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
- Access Services
- Audit Documentation Submission Guidance
- An online form to submit safe filling and billing questions
- Your PAAS Membership Manual
- Newsline
- Monthly newsletter articles, written by our expert PAAS analyst team, provide safe filling and billing tips and relays relevant/current PBM trends to be help prevent audits
- Search the Newsline Archive to get PAAS tips at the click of a button
- Special Edition Newslines including: Top 10 articles of the prior year, DMEPOS Article Series and a Self-Audit Article Series
- Ability to print monthly issues or individual articles
- Proactive Tips
- Audit flags – list of various claim attributes the PBMs use to select claims for audit
- Billing insulin vials – flowchart to assist whether you should bill Medicare Part B vs Part D
- DAW Codes Explained – use to understand when to effectively use DAW codes, their definitions and why claims may be flagged for audit if a DAW code is used incorrectly
- Basic DMEPOS documentation guidance
- Onsite Credentialing Checklist and expanded definitions of policies and procedures
- Proof of refill request and affirmative response form for DMEPOS items
- Steps on how to prepare for an onsite audit
- And more!
- Days’ Supply Charts
- Utilize the days’ supply charts for inhalers, insulins, nasal sprays, eye drops and topicals to aid you in calculating the correct days’ supply
- Guidance on overbilled quantities and incorrect days’ supply account for a sizable portion of audit chargebacks
- Additional miscellaneous charts, which include: Dispense in Original Container and Return to Stock
- Forms
- Signature Logbook for print
- Signature Trifold Mailer
- Fax and Email Coversheet
- Patient Attestation for over-the-counter COVID-19 test kits
- On-Demand Webinars
- Short webinars on hot topics in the PBM industry. Here are a few examples:
- USP 800 Compliance
- Cultural Competency Training
- Dispensing Prescriptions Off-Label
- Biologic Medications and Interchangeability
- Continuous Glucose Monitor Requirements for Medicare Part B
PAAS Tips:
- MORE AUDITS, MORE INSIGHT – PAAS National® is the industry-leading defender of community pharmacy dealings with Prescription Benefit Programs, including Caremark, Express Scripts, Humana, Medicaid, OptumRx, Prime Therapeutics., and more. PAAS assists on all third-party audits, including: desktop audits, onsite audits, invoice audits, OIG/Medicaid audits, Medicare B audits. The PAAS team is dedicated to helping you! We have five pharmacists and a complement of technician analysts with over 50 years of dedicated audit assistance experience. PAAS continuously updates their database with every audit received — in fact, we even keep a scorecard on individual auditors.
- Get answers to your questions on days’ supply calculations, drug substitutions, billing practices, required documentation, prior authorization requirements, record retention, and internal audit procedures – just to name a few. As a trusted partner, we will provide tailored guidance to help you proactively prevent audits. Remember, the prescription claims you submit today are the audits of the future.
- Keep your employees engaged and help lower audit risk by adding all employees to the portal and giving them permission to access these tools, resources and eNewsline. For more information review September 2019 Newsline article, What Are You Waiting For? Make Sure ALL of Your Employees are Added to the PAAS Portal!
- Contact PAAS at (608) 873-1342, if you would like a tour of your PAAS Member Portal, so you can reap all the benefits of your PAAS Audit Assistance. We appreciate you being a member.
Understanding Audit Risk with Insulin Prescriptions
Keeping up with all the new insulin products has become a full-time job. The range of delivery devices and concentrations continues to expand. Pharmacies need to stay informed about these updates to ensure their prescriptions meet audit requirements.
Recently, PBMs have flagged insulin prescriptions as …
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Guidelines for Dispensing Insulin Pens in their Original Carton
In 2019, the FDA required new labeling for insulin pen packages that states, “Dispense in this sealed carton”. The rationale was pursuant to a Tracked Safety Issue which cited concerns for dispensing errors, counterfeit product and failure to include the patient instructions for use with each dispensing. Since that time, PAAS National® has recommended …
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Medicare Drug Price Negotiation: MTF Data Module Enrollment & Caremark Attestation
Starting in 2026, Medicare has negotiated the price of 10 brand drugs under the Medicare Drug Price Negotiation Program as part of the Inflation Reduction Act of 2022. The negotiations between CMS and drug manufacturers have resulted in Maximum Fair Prices (MFPs).
To implement this program, CMS has created the Medicare Transaction Facilitator (MTF) which will capture pharmacy dispensing data for respective Part D claims and send it to drug manufacturers via the “Data Module” (DM) and then return refund payments from manufacturers back to pharmacies via the “Payment Module” (PM).
Medicare Part D contracts require that network pharmacies enroll in this MTF. Failure to enroll will result in pharmacies losing out on manufacturer rebate dollars that will be necessary to cover the cost of the drugs. There will be a lag time between dispensing claims and receipt of refund payments, which is likely to create a cash flow problem for pharmacies – for this reason, CMS is encouraging manufacturers to expedite payments to pharmacies that self-identify (during enrollment) as having material cashflow concerns.
In addition to enrolling in the MTF DM, we have seen that PBMs also want assurances that pharmacies are completing this enrollment. Caremark sent a Pharmacy Update in October, requiring that pharmacies attest by December 31, 2025 on Caremark’s website confirming enrollment in the MTF DM. Caremark threatens a non-compliance fee for failing to attest.
The negotiated MFPs are not publicly available, however enrolled pharmacies should be able to see claims/refund data on the Beacon website which is managing the DM/PM.
PAAS Tips:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Days’ Supply Rejections on Unbreakable Packages
PAAS National® analysts continue to see unbreakable packages on audits causing recoupment due to dispensing quantity and days’ supply issues. Below is a list of common scenarios:
Pharmacies should always …
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Do Not Let Santyl® Cause a Wound in Your Pocket
Santyl® ointment is a high dollar topical medication with specific instructions for application which carries high audit risk and potential recoupment from your pocket. Pharmacies need to follow the guidance below to help reduce their audit risk.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Evaluating the Days’ Supply of Migraine Medications
PAAS National® analysts continue to see as needed migraine medications undergo increased scrutiny during audits, and unfortunately, the auditors are (too often) successful in their recoupment efforts.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Are You Getting the Most from Your PAAS National® Membership?
While PAAS National® may be known for our best-in-class, hands-on audit assistance, we also offer insightful and educational information and resources that you may be missing out on! Below is a list of resources found in the Audit Assistance section of the Member Portal that could help ensure you and your pharmacy staff stay educated and informed when it comes to audits.
Updates will occur to these resources whenever necessary, like adding a drug to our Dispense in Original Container Chart or adjusting information on our days’ supply charts. If these resources are printed for easy viewing access, be sure to occasionally check on the website for the “Last Updated” section above these resources to ensure you have the most up-to-date version printed.
PAAS Tips:
DOJ Expands Health Care Fraud Units: What It Means for Pharmacies
The U.S. Department of Justice (DOJ) has announced an expansion of its Health Care Fraud Unit. The New England Strike Force—formerly responsible for Maine, New Hampshire, and Vermont—now includes Massachusetts. With this change, there are nine Health Care Fraud Strike Force locations nationwide, covering many of the country’s largest metropolitan areas.
The Health Care Fraud Unit is a specialized division within the DOJ that investigates and prosecutes fraud involving federal health care programs such as Medicare, Medicaid, and TRICARE. Its core mission is to protect taxpayer dollars, ensure patient safety, and uphold the integrity of the health care system.
For pharmacies, this expansion underscores the government’s increasing focus on detecting and preventing fraud related to billing, controlled substances, and prescription claims. The unit collaborates closely with the Office of Inspector General (OIG), Drug Enforcement Administration (DEA), and Federal Bureau of Investigation (FBI) to identify and prosecute fraudulent activities—including schemes involving unnecessary prescriptions, false claims, and diversion of controlled substances.
The DOJ relies heavily on data analytics and advanced algorithms to detect emerging fraud patterns and pinpoint high-risk behaviors. This means pharmacy billing and dispensing data may be analyzed for irregular trends or red flags, particularly in cases involving opioids or other controlled medications.
Pharmacies can reduce their risk by maintaining robust compliance programs, conducting regular internal audits, and ensuring accurate documentation of all prescriptions and reimbursements. As the Health Care Fraud Unit’s reach expands, proactive compliance and vigilance will remain essential for all pharmacy professionals.
PAAS Tips:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Why Copays for Pharmacy Staff Should NOT Be Waived
Successful pharmacies recognize the immense value of team members who are dedicated, diligent, knowledgeable, and reliable. With the financial squeeze in community pharmacies, payroll can be a tough spot to spend extra money. Having the employee fill prescriptions at the pharmacy they work in, and not having them pay the resulting copay, can be a nice gesture, but there may be consequences.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Pitfalls with the Most Common DAW Codes Billed
PBMs and audit companies pay close attention to how pharmacies bill claims, including which DAW code was used. This seemingly innocent billing element can cause significant audit issues if not used properly. Any DAW (other than 0) should have supporting documentation for why it was appropriate to use. PBMs will continue to pay close attention to this billing element due to pharmacy reimbursement and/or patient copay differences potentially being influenced by the billed DAW code. Below are the more common DAW codes we see billed and some considerations to take when processing a claim.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips: