The Department of Justice announced a Nebraska pharmacist, and owner of two pharmacies, was sentenced to two months of imprisonment, three years of supervised release, and ordered to pay restitution in the amount of $573,000.
The pharmacist was found guilty of making a false, fictitious, and fraudulent statement related to health care services. The investigation began in 2020 based on a tip to Federal Agents, and included pharmacy staff interviews, patient interviews and an inventory audit. The inventory audit reconciled claims billed to both Medicare and Medicaid with invoice purchases made by the pharmacy.
Upon completion of the investigation, the inventory audit identified significant shortages. Investigators discovered the pharmacist was billing for brand name drugs but ordering and dispensing the generics. Additionally, the pharmacist in question was submitting claims that were never dispensed to the patient.
PAAS Tips:
- PAAS Audit Assistance members can view these articles
Contact PAAS National®® today and start your robust Fraud, Waste and Abuse and HIPAA Compliance Program, ensuring your pharmacy employees are informed and trained against fraudulent activities.
Additional Audit Assistance Member Benefits
As we start 2024, keep in mind your Audit Assistance membership includes more than just assistance on audits and a monthly printed newsletter. Members have access to additional Newsline content online in the Member Portal, in addition to an archive of articles.
Plus, as a member benefit you have access to additional audit tactics and prevention tips:
PAAS Audit Assistance Administrators can keep their employees engaged and lower audit risk by adding employees to the Portal so the entire staff can access these resources and the eNewsline.
If you have any questions on accessing the Member Portal or need help adding employees, please contact us at (608) 873-1342 or info@paasnational.com and our staff can assist you.
Insulin Substitution Review: Understanding Purple Book Terminology
PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber. For biological products, pharmacies can refer to the FDA Purple Book to identify biosimilarity and interchangeability.
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:
Inventory Purchase Reminders for Successful Audits
With a 29% increase in PBM audits in 2023, PAAS National® wants to help you avoid PBM scrutiny, especially when it comes to drug procurement.
PBMs conduct invoice audits to confirm pharmacies have purchased enough medication to support the claims they have billed for. This is the primary method PBMs can identify false/phantom claims, where a pharmacy is billing for medications that never get dispensed. The auditor will reconcile claims billed with invoices provided, over a certain timeframe. After the reconciliation is complete, any inventory shortages must be explained or resolved by the pharmacy, or it could result in recoupment of claims and even termination of contract if there are substantial issues.
PAAS analysts have assisted with countless invoice audits and are eager to provide helpful tips for success.
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:
Need assistance with an invoice audit? Engage PAAS early for information and guidance for the best possible outcome. Call (608) 873-1342 or email to info@paasnational.com
Addressing “Weird” Days’ Supply
Days’ supply errors are one of the easiest audit triggers a PBM can pursue. Algorithms can be set for any days’ supply that does not correspond with typical dispensing of a medication and have an audit sent almost as soon as the claim adjudicates. We know that days’ supply should be billed based on the mathematically calculable directions, but what happens when the days’ supply does not fall in the easily calculable 30- or 90-day spectrum? What if it is “weird?”
The answer 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:
Caremark Bulk Purchase Notification
PAAS National® analysts continue to see a large volume of Caremark invoice audits. Remember that Caremark will only review aggregate purchases over the selected date range plus the 30 days prior to. If pharmacies want Caremark to consider purchases made prior to the selected date range, then there must be a “bulk purchase notification” on file in accordance with Section 8.05 of the Caremark Provider Manual. Since future audit date ranges cannot be known in advance, it is in your best interest to report any purchase that is subjectively “large” based on your normal purchase patterns – consider quarter or year-end bulk purchase if you are trying to meet wholesaler rebate thresholds or inventory that you are purchasing with intention to last greater than one month.
If your pharmacy plans to make any large purchases, be sure to …
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:
Adapting to Change: Levemir® Phase Out and Its Implications for Pharmacies
In November 2023, Novo Nordisk® announced that it would be phasing out the company’s long-acting insulin, Levemir®, in the United States. The company cited “global manufacturing constraints, formulary losses impacting patient access, and the availability of alternative options” as the reasons for discontinuing this medication.
The Novo Nordisk® website shows that supply disruptions of Levemir® FlexPen® would start mid-January with discontinuation complete on April 1, 2024. The Levemir® vial would be discontinued by December 31, 2024. Product will only be available while supplies last. There has been no indication that Novo’s other long-acting insulin, Tresiba®, is being discontinued.
PAAS National® has already seen some audit implications with this phase out of Levemir® products.
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:
Best Practices for DAW Billing in Pharmacies
In what should be a fairly straightforward process, proper DAW billing practices can be convoluted. Despite NCPDP guidance to standardize adjudication practices, PBMs do not always adopted these standards, leaving the pharmacy in a gray area of what proper DAW billing should look like.
Due to the variability between each PBM’s (and even individual Plan Sponsor) expectations for DAW billing, pharmacies need to have a multi-pronged approach that includes understanding biologic terminology (PAAS Audit Assistance members can see this month’s article, Insulin Substitution Review: Understanding Purple Book Terminology), a list of core “DAW billing guidelines” to follow, and additional considerations to guide your pharmacy in the scenarios where billing may not be straightforward.
Every claim adjudication comes with its own unique set of circumstances, making it difficult to establish a process that can be applied universally. Furthermore, audit tactics continue to morph and industry dynamics, such as the 2024 elimination of retroactive DIR fees, make the pharmacy’s reimbursement more transparent at point-of-sale, potentially driving DAW considerations. As such, having a grasp on the suggested DAW best practices is necessary.
PAAS Tip 1:
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:
Tip to Federal Agents Leads to Jail Time for Pharmacy Owner
The Department of Justice announced a Nebraska pharmacist, and owner of two pharmacies, was sentenced to two months of imprisonment, three years of supervised release, and ordered to pay restitution in the amount of $573,000.
The pharmacist was found guilty of making a false, fictitious, and fraudulent statement related to health care services. The investigation began in 2020 based on a tip to Federal Agents, and included pharmacy staff interviews, patient interviews and an inventory audit. The inventory audit reconciled claims billed to both Medicare and Medicaid with invoice purchases made by the pharmacy.
Upon completion of the investigation, the inventory audit identified significant shortages. Investigators discovered the pharmacist was billing for brand name drugs but ordering and dispensing the generics. Additionally, the pharmacist in question was submitting claims that were never dispensed to the patient.
PAAS Tips:
Contact PAAS National®® today and start your robust Fraud, Waste and Abuse and HIPAA Compliance Program, ensuring your pharmacy employees are informed and trained against fraudulent activities.
DMEPOS Updated Refill Request and Affirmative Response Requirements
Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims. If you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems during an audit. PAAS Audit Assistance members can download PAAS’ Basic DMEPOS Documentation Guidance resource for a helpful checklist when processing these claims.
This Newsline article focuses on the refill record request and affirmative response requirement that was updated January 1, 2024. Suppliers can find all the revisions in CMS Final Rule 1780-F. DMEPOS items and supplies that are provided on a recurring basis must be based on prospective, not retrospective, use. Medicare requires documentation to ensure the item(s) remain reasonable and necessary, existing supplies are expected to end, and to confirm if there are any changes to the order. If your pharmacy currently has a process for documenting a proof of refill request, PAAS National® would recommend you review and update your form if necessary to meet Medicare’s requirements.
The refill record request, at a minimum, must include:
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:
Don’t Cut Corners: Notations on Prescriptions
Not only are new medications frequently released to market, but also new strengths and formulations of existing medications. For example, consider Humulin® R U-100 insulin which was developed in the early 1980s. In the mid-1990s, Humulin® R U-500 vials became available in the market. That meant prescribers and pharmacists alike needed to be mindful of indicating which formulation of Humulin® R insulin the patient was to receive.
Not only are there new strengths of existing medications, but also new formulations. In 2016, Humulin® R U-500 insulin became available with a dedicated device used for the delivery of insulin – the KwikPen® – after previously only being available by vial. Yet again, this meant pharmacists needed to be explicit in what the patient was to receive, not only for the sake of the patient but also for accurate billing and dispensing.
For medications that come in one strength or dosage form, PBMs have proven to be more lenient with prescription hard copies that do not contain that information. However, medications that come in different strengths or dosage forms must include that information on the hard copy for it to be accepted by PBMs. Instead of trying to remember whether a medication comes in multiple forms, get all pharmacy staff into the practice of including strength and formulation for prescriptions, especially on telephone and transferred prescriptions. Below are the more common types of medications that could be recouped with missing information:
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: