In December 2024, a Tennessee pharmacist was arrested and charged with nine counts of Health Care Fraud and six counts of Aggravated Identity Theft for operating a health care fraud scheme that resulted in over $6 million worth of false claims being submitted to several insurers.
A federal indictment returned in late December revealed that a Tennessee pharmacist who oversaw a pharmacy with several locations in Tennessee, had been submitting false claims to Medicare, Medicaid, TRICARE, and Blue Cross Blue Shield for prescription drugs that were deemed not medically necessary, were not actually dispensed to a patient, or had no evidence of being ordered by a health care provider. In many instances, the pharmacist would use the identification of other people, without their consent, to receive reimbursement for claims submitted to a health care benefit program. The pharmacies profited from these schemes by receiving fraudulent reimbursement for personal use.
The case is being investigated by the U.S. Department of Health and Human Services, Office of Inspector General, the Tennessee Bureau of Investigation, and the Department of Defense, Office of Inspector General. If convicted, the pharmacist will face up to ten years in federal prison for each count of health care fraud, and two consecutive years in federal prison for the aggravated identity theft counts. The U.S. is also seeking a money judgement of $6,524,585.44, which represents the proceeds of the fraud scheme.
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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.
Caremark Aberrant Practices and Trends – Enforcement Extends Beyond the Aberrant Product List
PAAS National® analysts have worked with numerous pharmacies who have received communications related to Caremark’s proprietary Aberrant Product List or other alleged Atypical Dispensing Patterns. These letters are driven by Caremark’s Provider Manual section 3.02.03 which was expanded in 2022 as discussed in the Newsline article, Caremark® Expands “Aberrant” Language & Restricts Bulk Purchases.
These letters fall into two different categories:
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:
The NEW Inventory Transfer Log and Why it Could Save You Big!
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 following is a non-exhaustive list of potential issues leading to invoices not being accepted:
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.
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Continuous Glucose Monitor (CGM) Update – New Products Recently Released
There have been some updates to the continuous glucose monitor (CGM) world since our last Newsline article released March 2024. Abbott has released two new sensors, FreeStyle Libre 2 Plus Sensor and FreeStyle Libre 3 Plus Sensor, that can be used with the FreeStyle Libre 2 Reader and FreeStyle Libre 3 Reader, respectively.
FreeStyle Libre 2 Plus Sensor became widely available around June 2024, followed by the FreeStyle Libre 3 Plus Sensor a few months later. The biggest difference introduced with both sensors is…
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:
Using and Documenting Priming Units on Insulin Pens
In 1985, the first insulin pen was invented – it gave patients a flexible way of self-administration and autonomy from burdensome vials and syringes. Today there are a multitude of insulin products available as FlexPen®, FlexTouch®, KwikPen®, and Solostar® pens that offer convenience and discretion for patients with diabetes.
The patient Instructions for Use, included with insulin pen boxes, direct patients to prime the pen needle prior to administering each dose. This is for many reasons, including removing any air between the pen itself and the pen needle, ensuring the pen is properly working, and ensuring the correct dose is administered. The usual, reliable adage has been 2 priming units per dose, but some insulin pens require three to five priming units!
PAAS National® created the Insulin Medication Chart that includes which insulin pens deviate from the standard two priming units:
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:
Electronic Prescription Fraud
Most community pharmacy employees know the “red flags” to spot a fraudulent written prescription such as it “looks too good”, has irregular quantities and instructions, different color ink or handwriting, and doesn’t follow the typical medical shorthand.
Unfortunately, it is much harder to spot a fraudulent electronic prescription. The bad guys are now using sophisticated computer schemes to steal login credentials from prescribers and hijack electronic health record systems to initiate thousands of fraudulent e-prescriptions to pharmacies across the country within a short period of time. When these e-prescriptions are received at the pharmacy, the normal red flags are nowhere to be seen, and they may slip through undetected.
For these fraud schemes to pay off, the criminals must actually get their hands on the medications. Target medications are often not just controlled substances that can be sold on the street, but also expensive branded medications (dispensed in manufacturer stock bottles) that can be recirculated through an illegitimate supply chain. A Drug Topics article from April 2024 outlined these schemes including the use of “drug runners” to pick up medications from unsuspecting pharmacies.
Pharmacies need to be aware that the end-to-end electronic prescribing process, while generally secure, does have the potential to be exploited by criminals. It is important that both pharmacy technicians and pharmacists play a role to protect the integrity of this process. Pharmacies should consider some basic strategies to determine authenticity of e-prescriptions to ensure your pharmacy isn’t pulled unwittingly into a fraud scheme.
Below are some techniques to spot fraudulent electronic prescriptions at your pharmacy:
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:
Tennessee Pharmacist Conducts Multi-Million Dollar Health Care Fraud Scheme
In December 2024, a Tennessee pharmacist was arrested and charged with nine counts of Health Care Fraud and six counts of Aggravated Identity Theft for operating a health care fraud scheme that resulted in over $6 million worth of false claims being submitted to several insurers.
A federal indictment returned in late December revealed that a Tennessee pharmacist who oversaw a pharmacy with several locations in Tennessee, had been submitting false claims to Medicare, Medicaid, TRICARE, and Blue Cross Blue Shield for prescription drugs that were deemed not medically necessary, were not actually dispensed to a patient, or had no evidence of being ordered by a health care provider. In many instances, the pharmacist would use the identification of other people, without their consent, to receive reimbursement for claims submitted to a health care benefit program. The pharmacies profited from these schemes by receiving fraudulent reimbursement for personal use.
The case is being investigated by the U.S. Department of Health and Human Services, Office of Inspector General, the Tennessee Bureau of Investigation, and the Department of Defense, Office of Inspector General. If convicted, the pharmacist will face up to ten years in federal prison for each count of health care fraud, and two consecutive years in federal prison for the aggravated identity theft counts. The U.S. is also seeking a money judgement of $6,524,585.44, which represents the proceeds of the fraud scheme.
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 PBMs Insist on Understanding Dispense Quantity Changes
When a pharmacy dispenses a quantity other than what was prescribed, it requires documentation. PBMs will want to know the rationale, whether the quantity was increased or decreased. There are plenty of valid reasons a pharmacy may need to change the quantity, including …
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:
Keeping the Diagnoses Straight for GLP-1 Products
The FDA recently announced that Zepbound® (tirzepatide) has been approved for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity. This is the first GLP-1 indicated for OSA. The popularity of GLP-1 products has not slowed down, but with the new diagnosis for Zepbound® it is a good time to review the GLP-1 products and their FDA-approved diagnoses.
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:
Top Ten Newsline Articles for 2024
In today’s fast-paced world, it’s crucial to stay informed with the latest insights to avoid putting your pharmacy at risk. For all pharmacy staff, continuous education is key. Mailed to pharmacies with the January Newsline, this article reviews the top ten PAAS National® Newsline articles from 2024 that were the most read tips and trends to help be proactive in preventing audits.
In addition, below are the top articles that are available only on the Member Portal.
When using the PAAS eNewsline on the Member Portal, you are able to search the Newsline Archive via keyword. Let the knowledge from these articles fuel your journey toward improved operations and a more engaged pharmacy staff.
Access these popular articles via the links above or you can print the Top 10 Articles of 2024 resource for a quick read.
Unique Eyedrop Calculation Challenges
Pharmacy social media platforms host passionate discussions on the correct way to bill days’ supply for eyedrops almost every week. Do you use 15 drops/mL, 20 drops/mL, or something else? As it turns out, the “right answer” depends on the PBM you are billing and if the eyedrop is a solution or a suspension. Sound complicated? PAAS National® has a one-page chart and an app for that!
To make matters worse, there are some unique situations where using the PBM guidance is not relevant.
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: