As technology continues to reshape modern medicine, medical providers have embraced electronic prescribing to improve patient care. Unfortunately, as the healthcare landscape evolves, so do the tactics of bad actors seeking to exploit it.
Bad actors can use stolen login credentials from prescribers to gain access to electronic health record systems and initiate thousands of fraudulent e-prescriptions to pharmacies across the country within a very short period. For example, a 26-year-old Florida resident plead guilty in December 2024 and will serve two years and six months in federal prison for wire fraud and aggravated identity theft.
In response to this growing threat, the DEA is urging pharmacies to stay vigilant, as those that dispense fraudulent prescriptions may be held liable. For example, CVS agreed to pay $70,000 in 2023 to resolve allegations that the Controlled Substances Act (CSA) was violated at several of its locations.
According to an article published by Pharmacy Practice News, the DEA is on high alert. “Electronic prescription fraud is a real emerging trend that we’re seeing all across the country,” said Erin Hager, a DEA diversion investigator in the Phoenix-Tucson Tactical Division Squad. “What’s happening is … bad actors … who have been conducting prescription drug fraud are now utilizing the internet and electronic health record platforms to create electronic prescriptions that they can then send nationwide.”
What can pharmacies do to keep fraudulent prescriptions from being filled and dispensed? As mentioned in our February 2025 Newsline article, Electronic Prescription Fraud, we listed techniques to spot fraudulent e-prescriptions, like knowing the prescriber, the patient/caregiver, and reviewing the prescription for unusual items. The DEA has also released some helpful resources to help in preventing fraudulent prescriptions from being filled and dispensed, like the Pharmacists’ Guide to Prescription Fraud and the DEA Pharmacists’ Manual.
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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.
When Medicaid is the Secondary Payor
Billing insurance isn’t always simple, whether it’s formulary issues, step therapy or plan limitations, it’s common for a pharmacy to receive a rejection when trying to bill a patient’s insurance. For patients with Medicaid as secondary coverage, can you simply send the rejected claim to Medicaid? Caution should be exercised.
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:
Dexcom G6/G7 Sensors: Retail vs DME
PAAS National® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites with different list prices and they aren’t sure which product they can buy, and which payors will pay for what product.
PAAS has spoken with Dexcom officials who confirmed 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:
GLP-1 Prescriptions Remain in the Crosshairs of Auditors
GLP-1 medications continue to come under scrutiny from PBM auditors for several reasons. High cost, off-label use, rising utilization, and billing irregularities make these easy audit targets. Pharmacies must remain diligent to ensure accuracy and appropriateness when dispensing these medications to avoid recoupments.
The latest in audit recoupments have come from…
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:
COVID-19 Vaccine Update: Shared Clinical Decision-Making
The CDC recently revised recommendations for COVID-19 vaccination by (i) removing the recommendation for pregnant women to receive the vaccine and (ii) that individuals ages 6 months to 17 years may receive the vaccine using a shared clinical decision-making (SCDM) approach. The SCDM recommendations are meant to be flexible and informed by the characteristics, values, and preferences of the individual patient (or guardian) and the clinical discretion of the health care provider.
There are now five vaccines that follow the SCDM approach rather than routine, catch-up, or risk-based approach where the default is to “vaccinate, unless contraindicated”.
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:
Why Are There So Many Audits?
Many pharmacies that PAAS National® assists with audits have similar sentiments, “Why us?” or “We just had an audit with [insert PBM here]”. It can feel like it is a never-ending cycle, with shifting standards depending on which PBM is conducting the audit. At PAAS, we understand these concerns — and we’re here to help.
To support pharmacies in managing and minimizing audit risk, the PAAS portal includes a valuable resource under the “Proactive Tips”, called Audit Flags. This resource can help pharmacies identify characteristics of prescriptions that frequently trigger audits and provide insight into why they’re being flagged. While high-cost medications are commonly targeted, there are many other lesser-known reasons a claim might attract attention. For example, did you know…
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:
DEA Alert: Electronic Prescription Fraud on the Rise
As technology continues to reshape modern medicine, medical providers have embraced electronic prescribing to improve patient care. Unfortunately, as the healthcare landscape evolves, so do the tactics of bad actors seeking to exploit it.
Bad actors can use stolen login credentials from prescribers to gain access to electronic health record systems and initiate thousands of fraudulent e-prescriptions to pharmacies across the country within a very short period. For example, a 26-year-old Florida resident plead guilty in December 2024 and will serve two years and six months in federal prison for wire fraud and aggravated identity theft.
In response to this growing threat, the DEA is urging pharmacies to stay vigilant, as those that dispense fraudulent prescriptions may be held liable. For example, CVS agreed to pay $70,000 in 2023 to resolve allegations that the Controlled Substances Act (CSA) was violated at several of its locations.
According to an article published by Pharmacy Practice News, the DEA is on high alert. “Electronic prescription fraud is a real emerging trend that we’re seeing all across the country,” said Erin Hager, a DEA diversion investigator in the Phoenix-Tucson Tactical Division Squad. “What’s happening is … bad actors … who have been conducting prescription drug fraud are now utilizing the internet and electronic health record platforms to create electronic prescriptions that they can then send nationwide.”
What can pharmacies do to keep fraudulent prescriptions from being filled and dispensed? As mentioned in our February 2025 Newsline article, Electronic Prescription Fraud, we listed techniques to spot fraudulent e-prescriptions, like knowing the prescriber, the patient/caregiver, and reviewing the prescription for unusual items. The DEA has also released some helpful resources to help in preventing fraudulent prescriptions from being filled and dispensed, like the Pharmacists’ Guide to Prescription Fraud and the DEA Pharmacists’ Manual.
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:
AstraZeneca Letters re: Farxiga® Data Discrepancies
Numerous pharmacies have received letters from AstraZeneca, the manufacturer of Farxiga® 5 and 10 mg, regarding “discrepancies” identified in a reconciliation of purchase and dispensing data from 2024.
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 Semiannual Report to Congress Shows 11:1 Return On Investment
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Semiannual Report to Congress summarizing program integrity efforts from October 2024 through March 2025 which showed a return of $11 for every $1 spent. The OIG is the lead federal agency combating healthcare fraud, waste, and abuse in federal programs such as Medicare, Medicaid and providers will likely see increased activity based on President Donald Trump’s goals to pay for the One Big Beautiful Bill Act.
OIG Highlights from October 1, 2024 – March 31, 2025:
OIG oversight impacting pharmacies includes:
NCPDP Package Size Updates: Gonal-f® RFF Redi-ject® and Teriparatide (Alvogen)
Similar to the recent package size changes for Forteo®, NCPDP reports that the FDA has requested product labeling changes on four additional products which will be revised in compendia this summer. The FDA is not requiring manufacturers to obtain new NDCs and there are no clinical changes to the products.
Products with coming package size changes 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:
What’s New with Prescription Validation Requests in 2025?
In the PAAS National® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024. While we are not surprised that Ozempic® continues to be the top drug on the prescription validation requests, the others are not surprising either.
The top 5 comments noted by an analyst after claim review for the first half of 2025 mirror those from 2024.
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: