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
Caremark Invoice Audits – Pharmacy to Pharmacy Purchases
PAAS National® continues to see PBM audits increase as we get further out from the formal end of the COVID-19 Public Health Emergency. One disturbing trend is the number of invoice audits, particularly from Caremark. Oftentimes, Caremark will conduct a “combination” audit where they request copies of prescriptions and signature logs (a traditional desk audit) along with a request for pharmacy invoices that generally cover a 12-month period.
These audits are very large in size and scope, and we have noticed a new twist in enforcement on the invoice audits. Caremark outlines pharmacy network requirements for purchase invoices in the Pharmacy Provider Manual Section 8.05. Caremark states 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:
Are You Ready for Flu Shot Season? Auditors Are!
It is that time of year again; flu shot season is upon us. As busy as this season can be, we know you do not want to worry if you have all the documentation you need in case of an audit. Make it easy on yourself by ensuring you are ready now by following PAAS National®’s best practices to reduce your risk of audit recoupment.
What you will need for an audit:
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:
When Are Final Audit Results Not Final?
Receiving audit results with discrepancies and financial recoupments can be very discouraging. PAAS National® analysts are here to assist you through the appeal process. Audit results do not always provide all appeal options, and you don’t want to miss out on another chance if your initial appeal is denied.
Each PBM has different requirements for appealing discrepancies and different timeframes for when responses must be received. The appeal guidelines can also vary due to State audit laws. Engaging PAAS as soon as possible can make a big difference. PAAS analysts have years of experience with the audit appeal process and can provide information and recommendations to obtain the best possible outcome.
Many pharmacies give up when auditors do not accept appeal documentation and leave the fight too soon – check with your PAAS analyst to ensure you have exhausted all options. One example;
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:
Recent DEA Rule Change – Partial Fills for Schedule II Controlled Substances
The DEA recently updated the rule regarding partial fills of Schedule II (C-II) prescriptions. Pursuant to the Comprehensive Addiction and Recovery Act (CARA) of 2016, pharmacies are allowed to partial fill any C-II (e.g., stimulants, opioids, etc.) at the request of the prescriber, or the patient, as long as all the following criteria are met:
The change to 21 CFR 1306.13 (effective August 21, 2023) addresses regulatory requirements not previously addressed in CARA, such as how the prescribing practitioner should indicate the C-II should be partially filled, and how the pharmacist should record the partial fillings.
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:
Easy Audit Recoupment Prevention: Document Changes in Quantity Dispensed
When you think about preventing recoupments, ensuring the correct NDC is billed, the prescription contains calculable directions, and proper DAW or days’ supply are common focuses; and rightfully so. However, there is another element to be aware of when filling prescriptions: documenting when the dispensed quantity is different than the quantity prescribed.
Why?
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:
How to document?
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:
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:
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:
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:
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:
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:
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:
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:
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: