PAAS National® continuously monitors legislative and regulatory changes that may impact your Fraud, Waste & Abuse and HIPAA Compliance Program. We keep a close eye on enforcement from the Department of Justice, Office of Inspector General, State Attorney Generals, and Office for Civil Rights to help ensure the program meets interpretative standards. Furthermore, PAAS works to keep pace with Pharmacy Benefit Managers as they continue to add credentialing requirements that can be extremely difficult, and a significant nuisance, to independent pharmacies.
The PAAS National® FWA/HIPAA Compliance Program has implemented changes to ensure pharmacies continue to have a robust program in place. PAAS FWA/HIPAA compliance members can login to the member portal to view the 2023 FWAC and HIPAA Updates.
Administrators should review all Compliance tasks (located in the left-hand navigation on the PAAS Member Portal) at least annually to keep the program up-to-date and in compliance. Section 2.6 Updates of Policies and Procedures of your manual contains information on maintaining open lines of communication and the distribution of changes.
If you’re not a member of PAAS’ FWA/HIPAA compliance program, contact us today at (608) 873-1342 or info@paasnational.com to add the program for a discounted rate.
“We have been with PAAS for many years and added the FWAC/HIPAA material to our membership and as a compliance officer, I’ve never been more pleased with the program. If you have already made the best choice to have PAAS in your corner, then continue with the best for your FWAC/HIPAA needs.” – Member since 2010 from North Carolina
“PAAS National® Fraud, Waste, Abuse and Compliance educational sessions are unsurpassed. The PAAS National® Policy and Procedure manual that you create for your pharmacy is a must for all pharmacies to have for their staff. All of this keeps your pharmacy up to date with current pharmacy procedures and operations and ensure proper pharmacy practices going forward.” – Member since 2021 from New York
“A pharmacy without the compliance program does not have their bases covered and required work finished. I can sleep at night knowing this program keeps me protected and on task.” – Member since 2009 from Iowa
2023 Fraud, Waste & Abuse and HIPAA Compliance Program Updates
PAAS National® continuously monitors legislative and regulatory changes that may impact your Fraud, Waste & Abuse and HIPAA Compliance Program. We keep a close eye on enforcement from the Department of Justice, Office of Inspector General, State Attorney Generals, and Office for Civil Rights to help ensure the program meets interpretative standards. Furthermore, PAAS works to keep pace with Pharmacy Benefit Managers as they continue to add credentialing requirements that can be extremely difficult, and a significant nuisance, to independent pharmacies.
The PAAS National® FWA/HIPAA Compliance Program has implemented changes to ensure pharmacies continue to have a robust program in place. PAAS FWA/HIPAA compliance members can login to the member portal to view the 2023 FWAC and HIPAA Updates.
Administrators should review all Compliance tasks (located in the left-hand navigation on the PAAS Member Portal) at least annually to keep the program up-to-date and in compliance. Section 2.6 Updates of Policies and Procedures of your manual contains information on maintaining open lines of communication and the distribution of changes.
If you’re not a member of PAAS’ FWA/HIPAA compliance program, contact us today at (608) 873-1342 or info@paasnational.com to add the program for a discounted rate.
“We have been with PAAS for many years and added the FWAC/HIPAA material to our membership and as a compliance officer, I’ve never been more pleased with the program. If you have already made the best choice to have PAAS in your corner, then continue with the best for your FWAC/HIPAA needs.” – Member since 2010 from North Carolina
“PAAS National® Fraud, Waste, Abuse and Compliance educational sessions are unsurpassed. The PAAS National® Policy and Procedure manual that you create for your pharmacy is a must for all pharmacies to have for their staff. All of this keeps your pharmacy up to date with current pharmacy procedures and operations and ensure proper pharmacy practices going forward.” – Member since 2021 from New York
“A pharmacy without the compliance program does not have their bases covered and required work finished. I can sleep at night knowing this program keeps me protected and on task.” – Member since 2009 from Iowa
Natesto® Nasal Gel Pump – Bill It Right!
Pharmacies have begun to see more prescriptions for Natesto® (testosterone) nasal gel. Natesto® is indicated for primary hypogonadism and hypogonadotropic hypogonadism, whether those conditions were congenital or acquired. At this time, it is not approved for age-related hypogonadism or for male patient populations less than 18 years old.
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:
The Ballad of Snowbirds and Audits
The winter months have many pharmacies mailing prescriptions to their snowbird patients who leave their northern nests for more hospitable climates. Pharmacies want to keep these patients happy and coming back when the weather is nicer and may look to mailing maintenance medications to them when they have migrated out of state. Although these pharmacies may think they are doing the right thing for patient care, and their business, they may also be setting themselves up for audit failure.
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:
Start of New Year = Opioid Plan Rejects
PAAS National® analysts receive numerous calls at the start of the new year looking for guidance on opioid plan rejects. With the new year, many patients may be on a new Medicare Part D plan. Opioid prescriptions processed previously with no issues, may now reject at point-of-sale on the new plan.
With the opioid crisis on the rise, CMS acted in 2018 to closely monitor opioid use and safety of patients. Medicare Part D plans were required to implement opioid policies and work together with patients, prescribers, and pharmacies with this monitoring. These policies included real-time safety alerts at the pharmacy’s point-of-sale.
Here are the four Medicare Part D opioid safety alerts:
In August of 2022, CMS through the Medical Learning Network (MLN) published A Prescriber’s Guide to Medicare Prescription Drug (Part D) Opioid Policies. This guide offers guidance to both prescribers and pharmacies for patients using opioid medications. Pharmacies should note, alerts that cannot be resolved at point-of-sale may require providing patients with a copy of the CMS-10147 Medicare Prescription Drug Coverage and Your Rights form. This form provides instructions for patient to work with their prescriber and their Medicare plan to expedite coverage for their medication.
Pharmacies have an obligation to
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:
Update: Medicare Part D Mandatory E-Prescribing Requirements for Controlled Substances – Final Rule
In our December 2021 Newsline article, PAAS National® alerted pharmacies to the delay in enforcement of Electronic Prescribing for Controlled Substances (EPCS) for Medicare Part D until January 1, 2023. CMS has finalized policies in the Calendar Year (CY) 2021 Physician Fee Schedule (PFS) and CY 2022 PFS Final Rule for requirements on EPCS shown in section 2003 of the SUPPORT Act. Notably, in the CY 2022 PFS final rule, CMS finalized four proposals related to EPCS:
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:
FDA’s Guidance on Compounding Commercially Available Products in Short Supply
For various reasons, including ingredient shortages or manufacturer back orders, a pharmacist may be required to compound a commercially available product. This is currently the case for Amoxicillin Oral Powder for Suspension, as evident from the FDA’s Drug Shortage List. As a result of this shortage, the FDA released Compounding Certain Beta-Lactam Products in Shortage Under Section 503A of the Federal Food, Drug, and Cosmetic (FD&C) Act which was put into effect immediately due to the urgency of the situation, stipulating their guidance as nonbinding recommendations (not legally enforceable), except in cases where there are regulatory requirements that pharmacies must meet.
Products compounded by pharmacies are not FDA-approved and must follow Section 503A of the FD&C Act. Under Section 503A, leeway is given to pharmacies in that they do not need to meet specific requirements stated in the FD&C Act, namely new drug approval or current good manufacturing practice requirements. However, pharmacies are only allowed to compound a commercially available product if
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 Tool on PAAS Portal – DMEPOS Article Series 2022
PAAS National® wrote a DMEPOS article series in 2022, which includes 8 articles to be proactive in preventing audits. We recently combined these articles into one tool that PAAS Audit Assistance members can easily reference, read and review with their staff. The 2022 DMEPOS Article Series includes:
PAAS is continuously updating and creating new tools to help our members. Check out the Proactive Tips section of the members-only website to for a multitude of resources.
All employees can be granted access to the Member Portal to view these tools, along with the electronic Newsline. This also allows employees to send filling and billing questions to PAAS without having to call.
If you have questions about permissions and website access visit the ‘Member Portal User Guide’ located under ‘Help’ in the left-hand navigation (portal.paasnational.com/Paas/Help), or simply call PAAS at (608) 873-1342 for assistance.
PAAS Tips:
Prescriber Statement Requirements Needed for Prescription Discrepancies
Appealing audit discrepancies can be confusing and time consuming. PAAS National® analysts have over 50 years of dedicated audit assistance experience, and review nearly 10,000 audits a year. When PAAS is involved from the beginning of your audit, the average reduction is 89%! We are dedicated to helping our members survive predatory audits, compliance issues, or whatever new trick PBMs are springing on you. To ensure the best possible outcome, engage PAAS right away! Whether pre-audit and/or post-audit, PAAS will help members navigate the entire audit process and provide customized guidance to help keep your hard-earned money in your pocket! For an appeal, one of the most common tools is a Prescriber Statement. PBMs request validation or authorization from prescribers to support prescription discrepancies found by auditors. The requirements for these Prescriber Statements vary from PBM to PBM and missing any of these requirements can lead to denial of the appeal.
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:
2022 CVS Caremark Provider Manual Supplement for 2023
Caremark has released the 2022 CVS Caremark Provider Manual Supplement which is effective January 1, 2023. Pharmacies should have received a 23-page paper copy by mail and can also access it electronically on the CVS Caremark Pharmacy Portal at https://rxservices.cvscaremark.com/ (login required).
Unlike many PBMs that publish their Provider Manuals electronically on public websites, Caremark places theirs behind a password wall and chooses to mail 100-page plus paper manuals every even year (e.g., 2022) and shorter supplements during odd years (e.g., 2023).
The Provider Manual is an extension of the Provider Agreement (aka Contract) and pharmacies are “responsible for monitoring and complying” with these unilateral updates.
A few important 2023 CVS Caremark Provider Manual changes are as follows:
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:
Essential Elements of Corrective Action Plans
PAAS National® analysts have recently seen an increased number of PBM audits with “significant” results, including a large number of unique issues, large dollar amounts (>$100,000) or both. Audits of this magnitude may trigger further consequences such as additional audits, payment suspension and/or threat of network termination. In these instances, pharmacies may need to perform a documented “deep dive” and uncover the root causes and implement corrective actions to convince the PBM that there is no Fraud, Waste or Abuse and that it is safe to retain the pharmacy as a network provider. This deep dive is often referred to as a Root Cause Analysis or Corrective Action Plan (CAP). These CAPs are intended to improve operations moving forward and generally do not resolve the audit discrepancies or reduce the recoupment amounts.
While there is no mandatory format for CAPs, there are a few essential elements that should be considered.
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: