According to an August 18, 2023 press release from the Department of Justice (DOJ), a pharmacy operations manager and some co-conspirators have pled guilty to committing healthcare fraud and to paying illegal kickbacks for Medicare and Medicaid claims that were never dispensed to patients. The two pharmacies in New Jersey and New York, now closed, operated as “specialty pharmacies” processing expensive medications to treat Hepatitis C, Crohn’s disease, and rheumatoid arthritis.
The pharmacies in question obtained retail contracts with several PBMs, which allowed them to receive payment for the specialty medication claims that were falsely billed. In order to increase the number of prescriptions being filled, bribes were paid to doctors and their staff to steer prescriptions to their pharmacies. Some of the bribes were expensive meals, cash, checks, wire transfers and paying an employee to work inside a doctor’s office. While the pharmacies usually dispensed the initial prescriptions to the patients, they billed for refills of these same medications without ever dispensing them to the patients.
For five years, the pharmacies received tens of millions of dollars for claim reimbursement from Medicare, Medicaid and private insurances that were not only never dispensed, but never even ordered from their wholesaler. The PBMs began to investigate by conducting routine audits for these “specialty pharmacies.” One of the co-conspirators told employees to falsify records by forging shipping documents to make it appear as if the medications were being shipped to the patient when they were not. The conspiracy to commit healthcare fraud has a maximum sentence of ten years in prison and the conspiracy to pay illegal kickbacks has a maximum of five years in prison. Both counts face a $250,000 fine, or twice the gross gain or loss from the offence, whichever is greatest.
Ensure your pharmacy has a robust Fraud, Waste and Abuse Compliance Program in place for employees to understand the repercussions of violating laws and regulations such as the False Claims Act and the Anti-Kickback laws. Contact PAAS National® (608) 873-1342 for more information on PAAS’ FWA/HIPAA Compliance Program that is easy to set-up, web based and customized for your pharmacy.
Zepbound (tirzepatide) Means Decreased Audit Risk…Right?
On November 3, 2023, Eli-Lilly was granted the highly anticipated weight loss indication on their tirzepatide injection, ZepboundTM. ZepboundTM is indicated as an adjunctive therapy for adults with a body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) plus at least one weight-related comorbidity, such as type 2 diabetes mellitus, dyslipidemia, or hypertension – the same indication as Wegovy® and Saxenda®. Although this is an exciting advancement in the realm of GLP-1 agonist prescribing, PAAS National® would like to take this opportunity to update our members on what PBM trends we have seen thus far, draw attention to the guidelines laid out by PBMs and regulations in which we can rely on, and give our thoughts on the current audit situation in the hopes of allowing you to make the most informed business decision.
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:
Unveiling a Multi-Million Dollar Fraud and Kickback Scheme
According to an August 18, 2023 press release from the Department of Justice (DOJ), a pharmacy operations manager and some co-conspirators have pled guilty to committing healthcare fraud and to paying illegal kickbacks for Medicare and Medicaid claims that were never dispensed to patients. The two pharmacies in New Jersey and New York, now closed, operated as “specialty pharmacies” processing expensive medications to treat Hepatitis C, Crohn’s disease, and rheumatoid arthritis.
The pharmacies in question obtained retail contracts with several PBMs, which allowed them to receive payment for the specialty medication claims that were falsely billed. In order to increase the number of prescriptions being filled, bribes were paid to doctors and their staff to steer prescriptions to their pharmacies. Some of the bribes were expensive meals, cash, checks, wire transfers and paying an employee to work inside a doctor’s office. While the pharmacies usually dispensed the initial prescriptions to the patients, they billed for refills of these same medications without ever dispensing them to the patients.
For five years, the pharmacies received tens of millions of dollars for claim reimbursement from Medicare, Medicaid and private insurances that were not only never dispensed, but never even ordered from their wholesaler. The PBMs began to investigate by conducting routine audits for these “specialty pharmacies.” One of the co-conspirators told employees to falsify records by forging shipping documents to make it appear as if the medications were being shipped to the patient when they were not. The conspiracy to commit healthcare fraud has a maximum sentence of ten years in prison and the conspiracy to pay illegal kickbacks has a maximum of five years in prison. Both counts face a $250,000 fine, or twice the gross gain or loss from the offence, whichever is greatest.
Ensure your pharmacy has a robust Fraud, Waste and Abuse Compliance Program in place for employees to understand the repercussions of violating laws and regulations such as the False Claims Act and the Anti-Kickback laws. Contact PAAS National® (608) 873-1342 for more information on PAAS’ FWA/HIPAA Compliance Program that is easy to set-up, web based and customized for your pharmacy.
Insufficient/Missing Clinical Notes Yield Audit Recoupments
PAAS National® analysts are seeing more prescriptions flagged for recoupment when insufficient or missing information is not verified with a valid clinical note. Nothing is more frustrating than having the validity of the clinical notes questioned by a PBM auditor because they are incomplete, but that is exactly what is happening!
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:
Auditors Become Increasingly Stringent on Quantity and Unit of Measure Appeals
You may recall the article Quantity Changes Cause Audit Appeal Trouble from the May 2023 Newsline. The article discusses how PAAS National® saw an increase in the number of discrepancies for “unauthorized” refills. Consider the excerpt,
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:
Avoiding MedImpact Recoupments for Bypassing Plan Limits
Pharmacies receive many rejections while billing claims throughout the day. Paying attention to these rejection messages is key to avoiding audit recoupments, which may occur years later. One such rejection occurs when a pharmacy bills a claim that exceeds a plan limit. This can be due to:
Actions to consider 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:
Documentation Deep Dive: Meeting Auditors’ Standards in DUR and SCC
PAAS National® frequently sees claims audited that contain a clinical drug utilization review (DUR) or submission clarification code (SCC), particularly from Express Scripts and Prime Therapeutics. Auditors are looking for proper documentation when these codes are used, but pharmacies are often unaware of what this should 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:
All Pharmacies Face Medicare Part A vs Part D Billing Risks, Especially Combo Shops
Pharmacies that service long-term care (LTC) and assisted living facilities (ALF) as well as retail patients, known as “Combo Shops”, may not be aware of the potential recoupment risks from Medicare. PAAS National® wants to inform our members of these risks and how to best avoid them.
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 Financial Hardship Waivers
PAAS National® analysts have noticed an increase in PBM audits focusing on copay collection. These audits requested a copy of the pharmacies’ policies and procedures addressing copay collection and financial hardship.
In general, PBMs require that pharmacies collect copays at the point of sale and retain a “financial paper trail” to prove such collection took place. Pharmacies will be asked to provide check copies (front and back), credit card receipts with authorization numbers and bank deposit slips as evidence of receiving cash from patients. Pharmacies may also be required to provide Accounts Receivable balances and Coordination of Benefits billing information, where applicable.
If patients are unable to pay their copay and the pharmacy waives or discounts the copay due to financial hardship, then you must have a robust written policy explaining the details on how such a policy is operated.
In general, financial hardship policies should include 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:
PBM Audits: Letters to Patients for Prescription Verification
Pharmacies often see PBM audit letters requesting documentation to validate paid claims, but not very many see letters sent to their patients.
PBMs have increasingly conducted patient (and prescriber) verifications, in the form of letters sent, to validate claims billed by your pharmacy. These letters are often initiated as part of a PBM investigation where they are searching for fraud, waste, or abuse– if there are inconsistencies between the information provided by the pharmacy, patient, and prescriber this can be a sticky situation.
Letters to patients typically consistent of basic questions like:
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:
Avoid the Creon® Chargeback Catastrophe by Following THIS Billing Rule
Creon® is indicated for the treatment of exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions. Claims for these pancreatic enzymes find themselves on audits year after year, and the audit risk has just increased as …
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: