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:
Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!
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.
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:
Manufacturer Coupons: Why It’s Important to Read the Fine Print
While PAAS National® sees a vast array of PBM audits daily, did you know that claims billed to a manufacturer coupon can also be audited by the coupon administrator? Each manufacturer coupon…
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:
Fraudulent Prior Authorization Submissions Costs Pharmacy Over $1 Million
A Florida-based pharmacy plead guilty to healthcare fraud and agreed to pay over $1 million to resolve False Claims Act violations stemming from falsified prior authorizations. The pharmacy dispensed Evzio® (injectable naloxone product for emergency treatment of opioid overdose—discontinued in October 2020) which frequently required prior authorizations due to its high cost. Instead of sending the prior authorization information and/or forms to the prescribers, the pharmacy would complete the forms and, in some cases, sign the required forms. It was made to appear that the physician (not the pharmacy) was submitting the information. Pharmacy staff also provided false information to the insurer that the patients had tried and failed to successfully use Narcan®.
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:
Preventing Misfill Recoupments Through Documentation
PAAS National® recommends attention to detail when it comes to typing directions for patient labels. Pharmacies are often very familiar with prescribers and what they likely intended to include on the prescription, but didn’t. This can range from a specifying a quantity to providing detailed patient instructions. Unfortunately,…
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:
New PAAS Tool! Flowchart for Multi-Payor Claims with Conflicting Coverage
In last month’s Newsline article, “A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims, PAAS National® provided insight into the revised billing process for multi-payor claims where one payor prefers the brand and the other payor prefers generic. Due to the complexity of this billing process, a new PAAS tool has been developed, Conflicting Coverage: When One Payer Covers Brand and the Other Prefers Generic.
This new tool will provide staff with a billing flowchart to follow when the primary payor prefers brand and a second chart to follow when the secondary prefers brand. These flowcharts can serve as a quick reference guide that can be printed out and posted at the data entry station for easy reference. At the end of this new tool, there is a table with a more in-depth explanation of this multi-payor billing process.
While the majority of the pharmacy’s claims are likely to process through just one payor, it is not uncommon to have a patient with a secondary payor (e.g., Medicaid). While Medicaid as a secondary payor is not the only scenario where this tool will be helpful, it is likely the most common. Primary payors often have different formulary preferences for multi-source brand products than Medicaid due to various manufacturer rebates. PAAS analysts frequently receive questions about the proper way to bill these claims and which DAW code is appropriate to use. While an analyst is always happy to guide you through these scenarios, this tool can be at your fingertips and can also guide you through the process of how to correctly bill these claims.
Find this tool, and other amazing PAAS tools and aids, on the Member Portal. Here you can find Proactive Tips, Days’ Supply Charts, and even On-Demand Webinars! If you are not able to find something you’re looking for, just reach out to a PAAS representative for additional guidance.
Reduce Vaccine Audit Risk Through Accurate Quantity Billed
To enhance profitability, pharmacy owners and operators have frequently incorporated immunization services into their offerings. While vaccines tend to carry a lower audit risk, the higher the cost of the vaccine, the more likely it is to be audited. The audit risk also increases when core billing elements of the vaccine claim are adjudicated incorrectly.
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: