PAAS National® has recently assisted pharmacies who received fraudulent electronic prescriptions from prescribers that had their electronic prescribing credentials hacked or stolen. There was a recent widespread e-prescription fraud reported earlier this year where criminals issued over 18,000 prescriptions to pharmacies in 18 states in just a 5-hour span.
Fraudulent prescriptions that are billed to the patient’s insurance are subject to full recoupment when audited by the PBM. Unfortunately, pharmacies will need to cooperate with the PBM audit process and prove that they were not willing participants by explaining their process of “due diligence” to authenticate the prescriptions. To offset the financial losses from PBM recoupment, pharmacies will need to lean on their business insurance or separately pursue legal action against the perpetrators.
Of course, it would be much better to avoid dispensing (and billing) these fraudulent prescriptions from the start. Although electronic prescriptions are generally safer than written or telephone prescriptions, they are still vulnerable to exploitation by criminals targeting unsuspecting pharmacies.
Here are some techniques to spot fraudulent electronic prescriptions at your pharmacy:
Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!
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.
Auditors Are Drawn to Santyl® Like Moths to a Flame
Summer is here and so are the bugs! While mosquitos, gnats, moths and the like have next to nothing to do with Santyl® ointment for debriding chronic dermal ulcers and severely burned areas, the visualization of auditors being drawn to claims for Santyl® ointment being akin to moths (or other bugs) being drawn to a flame is a parallel not to be ignored.
A pharmacy billing a claim for Santyl® ointment is likely to see the claim audited in the future because Santyl® ointment has …
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:
Metformin HCl ER – Audit Considerations
Metformin HCl ER is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. It is commonly prescribed for patients who have gastrointestinal side-effects when taking the original. non-ER. version of the medication. Unfortunately, the cost difference can be significant, leading to an increased risk for audit – especially when a patient is taking Glumetza® or Fortamet®.
To add to the confusion, there are three different versions of metformin HCl ER, with three different extended-release mechanisms.
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:
Diabetic Test Strip Authorized Distributors
Independent pharmacies continue to receive threatening letters from LifeScan and an affiliated law firm on a monthly basis. These letters argue that pharmacies submitted more claims for LifeScan’s OneTouch® diabetic test strip products to PBMs than are supported by purchase history from authorized distributors. This is essentially an “invoice audit” conducted behind the scenes and pharmacies are not participants until they receive the negative results.
Additionally, these letters threaten to expose pharmacies to harm by withholding rebate dollars owed to PBMs and notify PBMs of the pharmacy’s “non-compliance” unless the pharmacy pays a large amount of money to make the issue “go away”.
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:
Ensuring Audit Readiness: What PBMs Look for in Signature Logs and Proof of Delivery
One of the most common questions PAAS National® receives from our members is: what are the requirements for audits when signature logs are requested. This article contains reminders and requirements auditors will be looking for to help ensure your pharmacy will be prepared.
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:
2024 Self-Audit Series #5: Topical Prescriptions
Topical medications are easy audit targets, especially with the rising costs of some of these medications. The discrepancy that is commonly cited for topical medications 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:
How to Safeguard Your Pharmacy from Fraudulent Electronic Prescriptions
PAAS National® has recently assisted pharmacies who received fraudulent electronic prescriptions from prescribers that had their electronic prescribing credentials hacked or stolen. There was a recent widespread e-prescription fraud reported earlier this year where criminals issued over 18,000 prescriptions to pharmacies in 18 states in just a 5-hour span.
Fraudulent prescriptions that are billed to the patient’s insurance are subject to full recoupment when audited by the PBM. Unfortunately, pharmacies will need to cooperate with the PBM audit process and prove that they were not willing participants by explaining their process of “due diligence” to authenticate the prescriptions. To offset the financial losses from PBM recoupment, pharmacies will need to lean on their business insurance or separately pursue legal action against the perpetrators.
Of course, it would be much better to avoid dispensing (and billing) these fraudulent prescriptions from the start. Although electronic prescriptions are generally safer than written or telephone prescriptions, they are still vulnerable to exploitation by criminals targeting unsuspecting pharmacies.
Here 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:
What’s New with Prescription Validation Requests in 2024?
In the PAAS National® January 2024 Newsline article PBM Validation Requests Rose 123% in 2023 – What You Need to Know, we discussed the PBM trends we saw in 2023. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2024 for comparison.
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:
Proper Billing of Nayzilam® and Valtoco® Nasal Sprays
A subset of patients who experience seizures due to epilepsy suffer from seizure clusters, despite being on maintenance epilepsy medications. Nayzilam® and Valtoco® are both FDA-approved for the “acute treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e., seizure clusters, acute repetitive seizures) that are distinct from a patient’s usual seizure pattern” in patients 12 years and older and 6 years and older, respectively. Regardless, if your patient is prescribed Nayzilam® or Valtoco®, the perplexing billing opens the door for easy recoupments from PBMs.
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:
On-Demand Webinar: Cybersecurity Considerations for Community Pharmacies
On May 8, 2024, PAAS National® hosted a webinar: Cybersecurity Considerations for Community Pharmacies. PAAS Audit Assistance members have access to the recorded webinar, in addition to many other tools and resources on the PAAS Member Portal.
In a world where threats lurk around every digital corner, safeguarding sensitive information has never been more crucial. Recent events, such as the Change Healthcare cyberattack, serve as stark reminders of the pressing need for robust cybersecurity measures. In pharmacies, where compliance with regulations like HIPAA are of great importance, the stakes are higher than ever.
President of PAAS, Trent Thiede, discussed:
Should you have any questions, or need assistance getting access, call 608-873-1342 or email info@paasnational.com.
PAAS Tips:
The Different Cyclosporine Eye Drops That Could Cause Audit Trouble
Cyclosporine eye drops are used to increase tear production in individuals with certain eye conditions and dry eye disease. You are likely familiar with Restasis® and Restasis MultiDose®, but the newest cyclosporine product Vevye®, hit the market in late 2023.
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: