The PAAS Member Portal is a wealth of information and resources, whether you are part of the Audit Assistance and/or Fraud, Waste, & Abuse and HIPAA Compliance Program. To get the most out of your membership, keep an accurate and up-to-date employee list.
Audit Assistance members: ensuring each staff member is entered into the PAAS Member Portal, along with a separate email address, allows for the entire staff to receive the monthly Newsline with current audit trends, proper filling & billing practices, hot topics, and more. They also have access to search seven years of eNewsline articles in our archive. Additionally, staff will have access to PAAS’ Tools & Resources, with billing charts, guidance documents, and on-demand webinars.
Fraud, Waste, & Abuse and HIPAA Compliance Program members: keeping your PAAS Member Portal current allows you to stay compliant. PAAS completes daily OIG & GSA exclusion checks, which goes beyond the federal expectation of exclusion checks being conducted upon hire and monthly thereafter. It allows the admin and compliance officer to generate a report reflecting when each employee last completed their FWA and HIPAA training and exclusion list check for the specific time frame being requested from the auditor.
In addition, if the auditor is looking for a specific policy or procedure, you can download your pharmacy’s customized FWA/HIPAA compliance manual and print off the corresponding pages of the policy or procedure they are requesting. For onsite audits, utilize PAAS’ onsite credentialing checklist to cross reference policy sections in your manual the auditor may ask for. This provides the auditor with much of the compliance components looked for during an audit in a fraction of the amount of paperwork and time.
PAAS Tips:
- Refer to the September 2021 Newsline article, “Why Should Your Pharmacy Keep the “Employees” Tab Updated in the PAAS Portal?”
- Contact us if you want to schedule time for a tour of your PAAS Portal, so you are able to reap all the benefits of your PAAS Audit Assistance and/or FWA/HIPAA Compliance membership
- Be mindful of students’ “termination date” within the PAAS Portal and when a new student/intern begins, add them to the PAAS Portal “New Employee”
- Termination dates can be inserted and, subsequently, removed for seasonal employees who may come and go throughout the year
Migraine Medications Continue to Cause Headaches
As PBMs continue to monitor claims for migraine medications, PAAS National® continues to receive questions about billing and the audit risks associated with these claims. When billing a medication to treat or prevent a migraine, pharmacies often struggle with having the correct documentation recorded for audit purposes. Submitting accurate quantities and days’ supply, along with appropriate documentation to support these claims, are the biggest issue PAAS comes across during an audit. PBMs monitor, and flag, these claims due to excessive cost, quantities submitted, days’ supply and/or frequency of refills.
PAAS Tips:
No safety studies for doses
> 3 mg/24 hours and 4 mg/7 days.
30-day period
Please reach out to PAAS (608) 873-1342 or info@paasnational.com with any questions on how to bill for different migraine medications so you don’t end up with a headache!
PAAS Pit Stop: The Member Portal
The PAAS Member Portal is a wealth of information and resources, whether you are part of the Audit Assistance and/or Fraud, Waste, & Abuse and HIPAA Compliance Program. To get the most out of your membership, keep an accurate and up-to-date employee list.
Audit Assistance members: ensuring each staff member is entered into the PAAS Member Portal, along with a separate email address, allows for the entire staff to receive the monthly Newsline with current audit trends, proper filling & billing practices, hot topics, and more. They also have access to search seven years of eNewsline articles in our archive. Additionally, staff will have access to PAAS’ Tools & Resources, with billing charts, guidance documents, and on-demand webinars.
Fraud, Waste, & Abuse and HIPAA Compliance Program members: keeping your PAAS Member Portal current allows you to stay compliant. PAAS completes daily OIG & GSA exclusion checks, which goes beyond the federal expectation of exclusion checks being conducted upon hire and monthly thereafter. It allows the admin and compliance officer to generate a report reflecting when each employee last completed their FWA and HIPAA training and exclusion list check for the specific time frame being requested from the auditor.
In addition, if the auditor is looking for a specific policy or procedure, you can download your pharmacy’s customized FWA/HIPAA compliance manual and print off the corresponding pages of the policy or procedure they are requesting. For onsite audits, utilize PAAS’ onsite credentialing checklist to cross reference policy sections in your manual the auditor may ask for. This provides the auditor with much of the compliance components looked for during an audit in a fraction of the amount of paperwork and time.
PAAS Tips:
Caution with Script Care Audits
PAAS National® has seen a rise in desk audits from Script Care. While this PBM may not be familiar to some pharmacies, we would like to share specific information they have been looking for on their audits.
Prescriptions we have frequently seen flagged discrepant are:
Script Care does not currently have a Provider Manual; however, PAAS has been informed that they plan to release one soon.
Remember to send in any audit request upon first receiving and a PAAS analyst will be happy to assist you through the audit process. You can send in your audits by fax (608) 873-4009, email info@paasnational.com or upload to our portal available on our website under Access Services.
Standard Written Order and Medicare Part B Audit Risks – New Guidance
If you are a Medicare Part B provider, then you know how cumbersome a Medicare Part B audit can be. For most Medicare Part B audits, a pharmacy would be required to provide a valid Standard Written Order (SWO), medical records to support the diagnosis and continued need of the item, proof of delivery, and proof of refill request if mailing or delivering supplies.
This article is going to focus on the SWO. In January of 2020, CMS finalized Rule 1713 which created a unified order for all DMEPOS items. While this new SWO was designed to reduce the burden on both suppliers and providers, audit results would prove otherwise. The required elements of an SWO are:
Below are the three most common SWO discrepancies PAAS National® sees on audit results and our guidance to help prevent these discrepancies from occurring.
PAAS Tips:
Alleged Inattentiveness to Details Costs Pharmacy $70,000
The DEA was established as a federal agency to regulate drug laws and to prevent misuse and/or diversion of both controlled substance and non-controlled medications. Their effort to prevent misuse and diversion of controlled substance medications starts with pharmacies filling prescriptions based on valid hardcopies. As was the case for CVS Pharmacies in New Hampshire, red flags that the federal government believes would have alerted a pharmacist of a fraudulent prescription were ignored, resulting in an alleged 41 fraudulent prescriptions being filled for Adderall®, Ritalin®, and Xanax ®. In order to resolve the allegations, CVS agreed to pay $70,000.
This civil case against CVS came as a result of two criminal investigations into individuals who utilized a variety of CVS Pharmacies around New Hampshire to fill fraudulent prescriptions. This speaks to the importance of ensuring the prescriptions that you are filling at your pharmacies are valid and written for a valid medical purpose by a provider within their usual scope of practice.
PAAS Tips:
Considerations With Ozempic 0.25 Weekly
PAAS National® analysts receive many questions on Ozempic® relating to concerns about off label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing.
Section 2.1 of the manufacturer’s product label (available on DailyMed) lists the recommended dosage schedule based on clinical trials and includes the following titration schedule:
What happens if the prescriber wants a patient to stay on the 0.25 mg dose for longer than 4 weeks? What if the prescription simply states “inject 0.25 mg weekly”? What days’ supply should the pharmacy transmit?
If you receive a new Ozempic® prescription with instructions of 0.25 mg weekly, we suggest that pharmacies follow-up with prescribers to discuss the manufacturer recommended dosage titration and confirm if patients will be titrating the dose to 0.5 mg or 1 mg weekly, and when. If the prescriber’s office confirms that the patient should stay on the 0.25 mg weekly dose for eight weeks, then the pharmacy should submit the claim as a 56-day supply (if possible) and provide the patient with additional pen needles to accommodate all needed doses. As a reminder, pharmacies may be required to bill a claim as a 30-day supply due to plan limits – in these situations, make sure to follow the Can You Bill It As 30 Days? process to ensure that you do not refill early.
PAAS Tips:
Electronic Clinical Notes: Are They Required?
There has been some discussion in pharmacy circles about clinical notes and whether PBMs are requiring them to be electronically annotated (or if hand-written clinical notes will continue to suffice).
First, DEA rule 21 CFR 1311.200(f) states that pharmacists must make and retain annotations electronically when filling an electronic prescription.
Second, be aware that state laws may require electronic annotations. For example, New York controlled substance rules mirror the DEA language when it comes to electronic prescriptions and annotations.
Third, while PBMs may not explicitly require electronic annotations, not having date and time stamped notes in your pharmacy software may be detrimental for audit appeals. Many PBMs are giving preference, or requiring, electronic date and time stamped clinical notes to appeal certain discrepancies successfully. With a date/time stamp, the detail provides validation to the PBM that they existed at the time of dispensing.
Examples:
PAAS Tips:
Desk Audits for Worker’s Compensation Claims
PAAS National® analysts have recently seen an increase in desk audits for worker’s compensation claims, mostly performed by Script Care. There has been a high rate of fraud with worker’s compensation in the past and these claims are subject to more scrutiny.
Many states have additional laws specific to worker’s compensation and auditors have often cited prescriptions as “invalid” if prescriptions did not conform to these specific laws.
A few common audit discrepancies include:
Upon first receiving an audit contact PAAS (608) 873-1342 so that an analyst can assist you from the start of the audit for the best results.
PAAS Tips:
Auditors Crack Down on Pharmacies That Bypass Plan Limits
PAAS National® analysts want to warn pharmacies about an uptick in PBMs flagging prescriptions for bypassing plan limit rejects. These prescriptions are being marked as discrepant and face full recoupment. Share this information with your staff and ensure that claims are not unintentionally being put at risk for audit/recoupment.
When pharmacies receive a reject of plan limit or exceeds maximum daily dose, pharmacy staff must follow the plan guidelines to submit the claim appropriately. The plan sending this rejection is telling the pharmacy that the dosage is not covered without additional requirements. This could mean prior authorization, switching to a different dose, or changing to another medication.
Pharmacies that manipulate the days’ supply to bypass the rejection are putting those claims at risk of recoupment. PBMs can easily track when pharmacies run a claim, receive a reject, and immediately rebill for the same quantity but different days’ supply. This raises a red flag that the plan reject was likely not adhered to appropriately – low hanging fruit for PBM auditors.
Reducing the quantity and/or split billing prescriptions can also be an audit risk. If a reduced quantity is submitted to bypass the plan limit (e.g., to get under a dollar threshold), the claim is still in jeopardy of being recouped. Beyond circumventing a plan limit, the payor may argue it increased costs through additional refills, dispensing fees, and patient copays. One patient complaint to their plan could lead to big trouble for network pharmacies.
PAAS Tips:
Nearly 90% of Cyber Breaches are Caused by…
Every day, pharmacies and their hardworking staff safeguard patients’ Protected Health Information (PHI), but breaches still occur. The June 2023 Health and Human Services Office for Civil Rights (OCR) Cybersecurity Newsletter focused on providing an insight into cybersecurity authentication and tips for building a more robust “wall” for malicious actors to encounter before a breach could occur. The OCR newsletter indicated that according to a 2023 Data Breach Investigations Report, “86% of [cyber] attacks to access an organization’s Internet-facing systems (e.g., web servers, email servers) used stolen or compromised credentials” and “robust authentication serves as the first line of defense against malicious intrusions and attacks”.
As mentioned in the OCR newsletter, the National Institute of Standards and Technology’s Digital Identity Guidelines believes that “historically, three factors form the cornerstones of authentication:
Multi-factor authentication is a common method for ensuring the person gaining access to a system is, in fact, who they say they are. It would require one element from two different bullets listed above, such as a password plus a security token. The Cybersecurity Newsletter states that “Cyber-attacks often begin with a compromised password that is used to gain initial access to an electronic information system.” If a password is compromised through a successful phishing attempt, the second element (e.g., security token) may be enough to block unauthorized entry long enough for the Security Officer to perform an Information Systems Activity Review and identify the unusual activity and intervene.
Safeguarding PHI and being compliant with the HIPAA Security Rule is required for any entity handling PHI. The Security Rule was designed to be flexible, allowing providers with varying scopes, sizes and resources to be compliant. Whether your pharmacy has been around for 30 years or 30 days, a thorough evaluation of your HIPAA program should be done at least annually. The beauty of the PAAS National® Fraud, Waste & Abuse (FWA) and HIPAA Compliance Program, is that it mirrors the flexibility of the HIPAA Security Rule and is anything BUT a cookie-cutter program. Pharmacies perform a risk analysis upon enrolling in the program and answer questions which allows us to customize a compliance policy and procedure manual specific to your pharmacy. PAAS Analysts are always happy to discuss how the PAAS FWA/HIPAA Compliance Program is built to help you address federal regulations. Call (608) 873-1342 or visit PAASNational.com to see how you can become an FWA/HIPAA Compliance member today.
PAAS Tips: