In December of 2019, Express Scripts (ESI) and Prime Therapeutics LLC (Prime) announced a three year partnership “designed to deliver more affordable care for clients and their members by enhancing pharmacy networks and pharmaceutical manufacturer value.” This partnership was designed to allow both companies to operate independently with ESI providing services to Prime, including performing some audits.
This partnership has led to some confusion for pharmacies since on-site audits have resumed around the country. ESI has been sending out numerous audit notices, all with ESI branding, which includes phrasing that the audit “may include one or more claims submitted to Prime Therapeutics, LLC.” If pharmacies miss this sentence, they may be underprepared when the auditor arrives having only reviewed ESI documents and forgetting to review Prime claims, and associated documents, as well.
Further confusion arises when results are returned. These results may be emailed to the pharmacy by an ESI auditor and include estimated chargeback amounts. The email may note that any estimated recoupments for Prime claims are automatically generated as 50% or 100% recovery based on the type of discrepancy found. The email also briefly states that Prime will send a statement with actual recoupment amounts once the audit is final.
Once the audit is final, and the pharmacy receives this Claim Adjustment Report from Prime, they may be confused again! This document will come with Prime branding, not ESI, and will have no link to the original audit beyond the prescription numbers that had been audited. Pharmacies may have a hard time understanding where this statement came from if they do not recall the brief mentions of Prime throughout the ESI audit process.
These adjustment reports will include the actual recovery amount and any refunds owed to the patient, usually due to a copay change. The pharmacy is expected to give this refund amount back to the patient and keep a record of doing so. Pharmacies are not allowed to request reimbursement from the patient if additional copays were incurred since the pharmacy is responsible for submitting claims correctly at the time of dispensing.
PAAS Tips:
- Send audit notices to PAAS National® as soon as you receive them for assistance deciphering requirements
- Send all audit results to PAAS to ensure appeal requirements are fully understood
- See June 2019 Newsline Prime Audit Adjustments Now Include All Claims for a more in-depth discussion of Prime’s Claim Adjustment Report
Prime Therapeutics and Express Scripts Partnership Muddies On-site Audits and Results
In December of 2019, Express Scripts (ESI) and Prime Therapeutics LLC (Prime) announced a three year partnership “designed to deliver more affordable care for clients and their members by enhancing pharmacy networks and pharmaceutical manufacturer value.” This partnership was designed to allow both companies to operate independently with ESI providing services to Prime, including performing some audits.
This partnership has led to some confusion for pharmacies since on-site audits have resumed around the country. ESI has been sending out numerous audit notices, all with ESI branding, which includes phrasing that the audit “may include one or more claims submitted to Prime Therapeutics, LLC.” If pharmacies miss this sentence, they may be underprepared when the auditor arrives having only reviewed ESI documents and forgetting to review Prime claims, and associated documents, as well.
Further confusion arises when results are returned. These results may be emailed to the pharmacy by an ESI auditor and include estimated chargeback amounts. The email may note that any estimated recoupments for Prime claims are automatically generated as 50% or 100% recovery based on the type of discrepancy found. The email also briefly states that Prime will send a statement with actual recoupment amounts once the audit is final.
Once the audit is final, and the pharmacy receives this Claim Adjustment Report from Prime, they may be confused again! This document will come with Prime branding, not ESI, and will have no link to the original audit beyond the prescription numbers that had been audited. Pharmacies may have a hard time understanding where this statement came from if they do not recall the brief mentions of Prime throughout the ESI audit process.
These adjustment reports will include the actual recovery amount and any refunds owed to the patient, usually due to a copay change. The pharmacy is expected to give this refund amount back to the patient and keep a record of doing so. Pharmacies are not allowed to request reimbursement from the patient if additional copays were incurred since the pharmacy is responsible for submitting claims correctly at the time of dispensing.
PAAS Tips:
Who’s Initiating Your Audit – Plan Sponsor, PBM or Audit Contractor?
There are numerous entities that may initiate and perform pharmacy audits. While the actual audit process does not vary significantly, there are a few important nuances to understand.
First, the further down the hierarchy (sponsor à PBM à audit contractor), the more opportunities for administrative headaches as each entity has their own processes to deal with. Typically pharmacies must “work their way up”, one level at a time. This does have a benefit in that it may offer more opportunities to appeal an unfavorable finding.
Second, audits initiated by plan sponsors are more common when there is suspicion of fraud, or the audit is labeled as an “investigation”. This is not to say that all audits initiated by sponsors are indications of additional threat.
Here are some examples of common players at each level:
PAAS Tips:
Best Practice for Entering Transfers with Partial Refills Remaining
Transfer prescriptions carry a high audit risk due to the additional documentation required based on state regulations. Pharmacies receiving transferred prescriptions know that sometimes the quantity received is not always a number that is easy to enter in the pharmacy’s software system. The following scenario outlines the most common issue.
If your pharmacy software system does not allow you to enter 90 tablets plus 2.7 refills, then the safest way to enter the prescription is for 333 tablets plus 0 refills, with a dispensed quantity of 90 tablets. However, beware of these additional audit pitfalls:
PAAS Tips:
Copays for Pharmacy Staff and Family
PAAS National® analysts occasionally field questions related to copay collection, particularly with respect to prescriptions for pharmacy employees and their families. While it is certainly most convenient to fill prescriptions at the pharmacy you spend 8-10 hours at every day, it is important to make sure that copay amounts due are collected and documented.
We frequently see PBM audits request documentation such as prescription copies and proof of copay collection for pharmacy employees – they are looking for pharmacies that may be cutting corners on documentation, billing claims where a valid prescription does not exist, or waiving copays as an employee benefit.
Please consider the PAAS tips below to avoid PBM audit problems.
PAAS Tips:
New Dispensing Platform? Be Ready in Case of an Audit!
Pharmacies updating or changing their dispensing platform may face unique audit issues. A top priority PAAS National® recommends for pharmacies going through a software migration is to ensure access to records from your old system. This accessibility is crucial in being able to respond to audit requests.
Record keeping requirements are often overlooked during software changes.
Storage of pharmacy files may be expensive, but audit recoupments for missing documents are typically costlier. Research your pharmacy’s record storage process to ensure you can access accurate and complete records in a timely manner in the event of an audit.
If you are acquiring a pharmacy (or their records), you must also be aware of potential audit pitfalls with these newly acquired records. Origin codes, overlapping prescription numbers, state transfer requirements and clear links to original prescriptions must be considered during the acquisition process. State Boards of Pharmacy can also be an excellent source for guidance during this process.
PAAS Tips:
Announcing Premier Cultural Competency Training by PAAS National
Beyond PBM requirements and NCPDP attestations, pharmacies need to provide services to all patients in a culturally competent manner – free of discrimination. The PAAS Cultural Competency Training uses real-life, pragmatic examples to serve as a launching pad for enhancing patient experiences at your pharmacy. PAAS’ unique approach to training ensures its content resonates with all pharmacy staff, making the goal of cultural competence achievable, across the board.
Developed by community pharmacists for community pharmacies, discover the PAAS CARE model difference:
If done correctly, pharmacies also have the opportunity to elevate their business. Become the more competitive pharmacy in your town and get the PAAS Cultural Competency Training Program today! Learn more at paasnational.com/culturalcompetency or contact PAAS at (608) 873-1342 or info@paasnational.com.
LIVE WEBINAR JUNE 15th: Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency
Join President of PAAS National®, Trenton Thiede for a LIVE webinar “Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency”
Hope to See You In-Person at an Upcoming Event!
PAAS National® will be at the following upcoming events and we hope to see you in-person. Visit the PAAS team at:
PAAS will be presenting an audit prevention seminar at each of these events. Be sure to attend and stop by the PAAS National® booth in the convention exhibit hall to connect with us. We appreciate the opportunity to hear live feedback from our members.
For more details on these events, visit: https://paasnational.com/news-and-events/.
Are Your Patients Running Out of Supplies for Their Continuous Glucose Monitor?
Pharmacies often struggle with audits for DMEPOS items. The Medicare Part B/DMEPOS billing model is a complex maze of units, codes and documentation requirements that are very different from billing traditional prescription drugs. This model produces high error rates and recoupments across the country. You must have a strong understanding of these differences to prevent audit recoupment. This article discusses how to bill supplies for Continuous Glucose Monitors (CGMs).
PAAS Tips:Join today!
- When a CGM Receiver/Monitor code of K0554 is covered, the related supply “allowance” code K0553 is also covered
- A monthly supply allowance includes all supply items needed for the patient to use the non-adjunctive CGM. These supply items may include transmitters, sensors, batteries, strips, lancets, and control solution for a Blood Glucose Monitor (BGM)
- These supply items can NOT be billed separately, or they will be denied
- See the April 2022 Newsline article, Billing Blood Glucose Test Strips for a Patient Who Utilizes a CGM for billing and payment classifications whether the CGM is Non-Adjunctive or Adjunctive
- Use the following steps to prevent patients from running out of supplies before month end
- Only bill 1 unit of service (UOS) for HCPCS code K0553 per month
- 1 UOS equals 1 month’s supply no matter if 28, 29, 30 or 31 days in the month
- If using a FreeStyle Libre, providing 2 (14-day) sensor packs will leave the patient short on days 29, 30 or 31
- The following example from the Medicare Learning Network® is a way to ensure the patient has enough supplies per calendar month
- April – 30 calendar days: Provide 3 sensors (42-day supply)
- May – 31 calendar days: Proved 2 sensors (28-day supply) since the patient should have 12 days remaining from the previous month
- June – 30 calendar days: Provide 2 sensors (28-day supply) since the patient should have 9 days remaining from the previous month
- Pharmacy will need to dispense 3 (14-day) sensors twice per calendar year
- Check with patients often to see what supplies they need and send enough to meet the next month’s supply need
- Remember, Medicare pays a bundled rate for the 1 UOS each month so you are still getting paid for the two extra sensors provider through the year. See the July 2021 Newsline article, Are You Billing Continuous Glucose Monitors Correctly?
Updated COVID-19 Vaccine Attestations Plus Resource and Billing Chart on PAAS Member Portal
On March 29, 2022, the CDC and FDA issued press releases to provide updated COVID-19 vaccine recommendations. In addition to the primary series and initial booster dose, they authorized an additional mRNA booster dose for people over the age of 50 and for certain immunocompromised individuals. The additional booster dose can be given if at least 4 months have passed since the patient received their first booster dose.
Keeping track of which patients are eligible, when they are eligible, and having documentation to confirm their eligibility can be a tiresome task with the constantly revised recommendations. PAAS National® has continued to update the COVID-19 Vaccine Self-Attestation form in an effort to streamline the COVID-19 vaccination screening process for pharmacies. There is a self-attestation form for immunocompromised patients obtaining an additional dose to complete their primary series and a form for patients obtaining a booster dose. Each form conveniently displays eligibility criteria including patient age, a sample list of qualifying patient conditions, and appropriate dosing intervals, and provides links to additional resources.
In addition to the self-attestation form, the COVID-19 Vaccine Resource & Billing Chart has also been updated to reflect the newest recommendations for a second booster and information on the new Moderna COVID-19 vaccine to be used only for booster doses (NDC 80777-0275-XX). The Moderna COVID-19 vaccine vials with a dark blue cap and label with a purple border are to be used only for booster doses and require 0.5 mL for the 50 mcg dose as opposed to the original Moderna COVID-19 vaccine vials with a red cap and label with a light blue border (NDC 80777-0273-XX) which require only 0.25 mL for the 50 mcg booster dose.
We recommend frequently checking the COVID-19 Resources tab on the PAAS Member Portal for the most up-to-date self-attestation forms, COVID-19 Vaccine Resource & Billing chart, and COVID-19 PBM Concessions document. Additionally, thank you to those pharmacies who have forwarded us PBM communications regarding the pandemic and COVID-19 waivers. We appreciate your time and efforts and would like to remind pharmacies to continue to forward those PBM notifications to PAAS as they may be valuable for future audits.
PAAS Tips: