Last month we wrote an article entitled: Guidelines for Dispensing Insulin Pens in their Original Carton. A few days later, the Office of Inspector General (OIG) announced that CVS had agreed to a $37.76 million settlement for violations of the False Claims Act by over-dispensing insulin pens between 2010 and 2020. Investigators found that Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program made significant overpayments for these prescriptions.
The overpayments stemmed from CVS pharmacies submitting incorrect days’ supply information, which allowed claims to be refilled earlier than appropriate. Updated package instructions promote dispensing insulin pens in their original carton, whereby the amount of insulin in a full box often exceeds plan limits. CVS pharmacies billed inaccurate days’ supplies and then refilled prescriptions before meeting the appropriate utilization threshold.
PAAS National® first notified members via email alert in January 2019, followed by a Newsline article in March 2019 titled, Breaking Insulin Boxes—Your Questions Answered, after the OIG announced a $269.2 million civil healthcare fraud settlement with Walgreens. The primary issue in this settlement involved the overpayments of insulin pens.
Automatic refill programs were a major contributor to this over-dispensing. Many patients received insulin far earlier than needed because pharmacies utilized the submitted days’ supply rather than the actual days’ supply. Since third-party payors can only reject early refills when an accurate days’ supply is reported, their ability to prevent inappropriate refills was “limited”.
Do not let your pharmacy fall into this same situation. Stay vigilant by ensuring your staff is trained to bill correctly when the smallest package size exceeds a plan limit. Utilize the automatic refill programs appropriately and safeguard your claims from audit recoupment and further scrutiny.
PAAS Tips:
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.
$300,000 Settlement for Employing Excluded Individual
The U.S. Attorney’s Office for the District of New Hampshire recently announced a $300,000 settlement with a telehealth company and its owner to resolve allegations of improper Medicaid billing under the False Claims Act. The government alleged that the company billed Medicaid for services provided by an individual who was excluded from participation in federal health care programs by the HHS Office of Inspector General (OIG). Federal rules prohibit payment for any services furnished by an excluded individual.
Although the excluded individual was criminally prosecuted for health care fraud, the company he worked for was responsible for civil damages to resolve their liability to the government. All healthcare providers (including pharmacies) that contract with federal payors like Medicaid and Medicare are responsible for ensuring that they do not employ any excluded individual. Pharmacies must screen employees prior to hire and monthly thereafter; and maintain records of these checks for 10 years!
PAAS National® can help you perform these checks as part of the PAAS Fraud, Waste and Abuse & HIPAA Compliance Program. Our proprietary exclusion checking algorithm runs daily with the Office of Inspector General (OIG) and General Services Administration (GSA). We’re also one of the few vendors who can, and do, identify exact matches. Additionally, all historical checks are kept in a secure, password-protected portal for you to access at a moment’s notice.
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:
Prescriber Statements Made Simple
Several audit discrepancies can be resolved by obtaining a letter from the prescriber clarifying their intentions for a prescription they wrote. While PAAS National® often gets requests for a template/form letter, this is problematic and impractical (except for Humana). PBMs have their own requirements and no two prescribers would write their letters using the same format – PAAS has seen auditors challenge or deny statements when it appears the pharmacy prepared them. It should come as no surprise – auditors do not want to make prescriber statements easy to obtain. The most common PBM requirements are as follows:
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:
Two Liraglutide Products That Are NOT Therapeutically Equivalent?
PAAS National® alerted pharmacies to the launch of the first ‘generic’ GLP-1 receptor agonist, liraglutide, back in late June 2024. The product released was an Authorized Generic (AG) of Victoza®. In August 2025, another liraglutide product was approved and released to the market as an Abbreviated New Drug Application (ANDA) of Saxenda®. With this release may come confusion as the liraglutide products may be labeled similarly but treat different indications.
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 Cost of Waiting: Delayed Return to Stock Procedures and Their Hidden Audit Risks
Pharmacies face audit risks in their everyday operations, and staying ahead to protect claims from audit recoupments can be exhausting. PAAS National® analysts continue …
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:
Interested in a customized FWA/HIPAA Compliance Policy and Procedure program? Contact PAAS National® at info@paasnational.com or (608) 873-1342 to get started today!
Notable Updates From the 2026 CVS Caremark Provider Manual
CVS Caremark updates, and mails, their complete provider manual in a hardcopy version to member pharmacies every other year, on even years. Pharmacies should have received a printed copy of the 2026 Caremark Provider Manual towards the end of last year. Undoubtedly due to congressional pressure, and as discussed in this month’s feature Newsline article: U.S. House Judiciary Committee Releases Scathing Report on CVS Health, there are several notable changes (particularly Section 4.12) found within the 114-page provider manual:
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:
340B Claim Identification Requirements
As part of the NCPA 340B task force, PAAS National®® has advocated strongly that pharmacies should not be required to identify 340B claims. The individual claim’s status is typically unknown at the point of sale, and the process to update claims (N1 information exchange transactions), or reverse and rebill, is arduous. Not only is it more labor intensive, but it’s also a matter of timing when product is replenished.
However, pharmacies participating in 340B should be aware of the claim identification requirements, as stated in the various PBM Provider Manuals. Consider the following…
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:
Caremark Rx Claim Review – Is This Trouble for My Pharmacy?
Pharmacies have sent PAAS National® notices from Caremark entitled “CVS Caremark Rx Claim Review.” The first line of the notice says, “This communication is for educational purposes only and is not part of an audit.” This has led to many questions and confusion amongst the pharmacies receiving these notices. PAAS has seen waves of these letters over the years. The medications targeted have changed over time, but the wording is nearly the same.
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:
New Year, Same Routine: Tips for Ensuring Accurate Billing
For pharmacies, the new year is often hectic. PAAS National®® is here to help make your transition into the new year less stressful by highlighting important billing considerations and 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:
OIG Report: Medicare Payments for Continuous Glucose Monitors
A recent OIG report found that Medicare may be overpaying suppliers for Continuous Glucose Monitors (CGMs) and supplies relative to other payers.
The report highlighted the following:
As a result of the findings, OIG has recommended that CMS reduce payments for CGMs and supplies and address improper use of billing codes to reduce overpayments.
CMS has included Class 2 CGMs and supplies in the next round of the DMEPOS Competitive Bidding Program as per Final Rule (CMS-1828-F) published December 2, 2025 which would both reduce prices and limit the number of suppliers eligible to bill for CGMs and related supplies. This process is expected to begin in 2026 and be completed no later than January 1, 2028. Previous rounds of competitive bidding yielded an average savings of 35% relative to the fee schedule prices.
The DMEPOS MAC for Jurisdictions B and C have posted the Medical Review Quarterly Reports for Targeted, Probe, and Educate (TPE) audits covering July to September 2025 and found that Glucose Monitors & Supplies have an 18.52% error rate overall and provides the top 10 denial reasons.
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:
$37.76 Million CVS Insulin Pen Case Settled
Last month we wrote an article entitled: Guidelines for Dispensing Insulin Pens in their Original Carton. A few days later, the Office of Inspector General (OIG) announced that CVS had agreed to a $37.76 million settlement for violations of the False Claims Act by over-dispensing insulin pens between 2010 and 2020. Investigators found that Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program made significant overpayments for these prescriptions.
The overpayments stemmed from CVS pharmacies submitting incorrect days’ supply information, which allowed claims to be refilled earlier than appropriate. Updated package instructions promote dispensing insulin pens in their original carton, whereby the amount of insulin in a full box often exceeds plan limits. CVS pharmacies billed inaccurate days’ supplies and then refilled prescriptions before meeting the appropriate utilization threshold.
PAAS National® first notified members via email alert in January 2019, followed by a Newsline article in March 2019 titled, Breaking Insulin Boxes—Your Questions Answered, after the OIG announced a $269.2 million civil healthcare fraud settlement with Walgreens. The primary issue in this settlement involved the overpayments of insulin pens.
Automatic refill programs were a major contributor to this over-dispensing. Many patients received insulin far earlier than needed because pharmacies utilized the submitted days’ supply rather than the actual days’ supply. Since third-party payors can only reject early refills when an accurate days’ supply is reported, their ability to prevent inappropriate refills was “limited”.
Do not let your pharmacy fall into this same situation. Stay vigilant by ensuring your staff is trained to bill correctly when the smallest package size exceeds a plan limit. Utilize the automatic refill programs appropriately and safeguard your claims from audit recoupment and further scrutiny.
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: