By now, most pharmacies are probably aware of Humana’s $5 administrative fees to correct, what other plans consider, educational discrepancies. We commonly see these fees assessed for incorrect prescriber (for legend drugs), invalid days’ supply, and incorrect origin code. State audit laws have been ineffective at protecting pharmacies from these clerical errors as Humana classifies these takebacks as “Administrative Fees”, not recoupments on the initial claim.
What should your pharmacy do when assessed a $5 fee? 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.
Disputing Humana’s Bogus $5 Administrative Fees
By now, most pharmacies are probably aware of Humana’s $5 administrative fees to correct, what other plans consider, educational discrepancies. We commonly see these fees assessed for incorrect prescriber (for legend drugs), invalid days’ supply, and incorrect origin code. State audit laws have been ineffective at protecting pharmacies from these clerical errors as Humana classifies these takebacks as “Administrative Fees”, not recoupments on the initial claim.
What should your pharmacy do when assessed a $5 fee?Join today!
- 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
- 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.
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:
Split Billing Opioid Prescriptions
PAAS has received numerous questions related to split-billing opioid prescriptions to insurance and cash. The current state of the opioid crisis has made these claims targets for audit recovery and DEA scrutiny.
PAAS recommends …Join today!
- 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
- 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.
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:
Prime Recovering Claims on Drug Substitutions
PAAS has seen Prime Therapeutics recover claims for the following reasons:
Inappropriate Billing Practices are discussed in the Prime Provider Manual, Section 2 and Unacceptable Billing Practices are found in Section 6. Here are a few examples:
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:
Pharmacist Sentenced to 10 Years in Prison for Fraud Scheme
Ademola Adebayo was convicted on January 11th, 2019 of conspiracy to commit health care fraud, wire fraud and money laundering. His sentence included 120 months (10 years) in prison followed by three years of supervised release and an order to pay $3.2 million in restitution and $1.4 million in forfeiture.
Adebayo was involved in a $121 million-dollar scheme that submitted false and fraudulent claims to Medicare, TRICARE, and private insurance companies. The claims involved compounded pain and scar creams, as well as other prescription medications that were either not medically necessary, never provided or both.
Adebayo was originally the pharmacist at A to Z Pharmacy in New Port Richey, FL. When the fraud was discovered in 2014 and plan contracts terminated with A to Z Pharmacy, Adebayo became a straw owner of Havana Pharmacy & Discount in Miami, which was used to continue the fraud scheme.
Eight other defendants have also been convicted. Others involved in the scheme admitted to paying kickbacks for prescriptions (and patient information) and physicians signing prescriptions for patients they never saw. All were sentenced to prison from one to fifteen years.
PAAS reminds pharmacies to have comprehensive Fraud, Waste, & Abuse Compliance policies and training. Contact PAAS today for more information on our customized Fraud, Waste, & Abuse and HIPAA Compliance Program at (608) 873-1342 or info@paasnational.com.
Test Claims are Prohibited and Put Pharmacies at Risk
Pharmacies may receive requests to determine if a specific medication is covered on formulary or what the copay will be in the absence of an actual prescription. While this may seem like a harmless request, “test claims” are generally prohibited by third-party payers. If your pharmacy submits a claim to insurance without a prescription, a PBM could cite this as a false claim or even fraud.
Payer concerns with test claims 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:
Authorized Generic vs. ANDA Generic
Since the recent launch of authorized generic albuterol inhalers, PAAS has received numerous requests for clarifications on substitution, therapeutic equivalence codes and DAW codes. PAAS Audit Assistance members can see our January 2019 article Generic Albuterol HFA Inhalers for additional background.
Q1: Is an Authorized Generic drug the same thing as a generic drug?
The FDA has a complete explanation on its website, here is an excerpt:
“No. The term “authorized generic” drug is most commonly used to describe an approved brand name drug that is marketed without the brand name on its label. Other than the fact that it does not have the brand name on its label, it is the exact same drug product as the branded product.”
Q2: How Is an Authorized Generic Drug Different from what Is Commonly Understood to Be a Generic Drug?
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:
Patient Copay Collection, and Documentation, is a MUST
Copayments are used by insurers to sensitize patients to the cost of their medications and give patients financial incentives to reject medications that are not medically necessary or add little to no value to patients’ treatments.
Third Party contracts obligate pharmacies to collect patient copayments in full; however, merely collecting copayments upon dispensing is not nearly enough. You must also be able to show proof of copay collection. PAAS continues to see pharmacies struggle with copay collection documentation due to inferior Point of Sale systems, poor record keeping, and banking relationships.
In order to show proof of copay collection, PBMs may ask for: front and back copies of canceled checks, bank deposits, and even Credit Card Merchant Account Reporting, including evidence of settlement and payment through bank records.
Stop and think for a moment about how you would prove copay collection.
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:
Financial recoupment on claims where you cannot show proof of copay collection should be the least of your worries. Network termination may ensue, and the pharmacy risks a Fraud, Waste, and Abuse investigation and charges stemming from the False Claims Act. Copay collection is not worth putting your license, and pharmacy, at risk!
Generic Albuterol HFA Inhalers
On January 15, 2019, GSK announced the availability of the first authorized generic Albuterol Sulfate HFA inhaler. This inhaler is the authorized generic for GSK’s Ventolin HFA® and will continue to be manufactured by GSK and distributed by Prasco Laboratories, LLC.
As the authorized generic, it is only a substitute for Ventolin HFA®. Other albuterol HFA inhalers, including Proventil HFA® and ProAir HFA®, continue to be BX-rated and not considered equivalent.
Not to be outdone, on January 17th, 2019, Teva launched an authorized generic. This inhaler is the authorized generic for Teva Respiratory’s ProAir HFA® and will be manufactured by IVAX Pharmaceuticals (IVAX was acquired by Teva in 2006) and marketed by Teva.
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:
Humana Begins Enforcing Mail Order Prohibition
In July of 2017, Humana updated its Retail Pharmacy Provider Agreement to prohibit the delivery of prescription drugs, Durable Medical Equipment, and prescribed diabetic supplies through mail delivery services. These services include the U.S. Postal Service, UPS, DHL, FedEx, or any similar national, regional, or local common carriers.
PAAS National® is seeing termination notices sent to pharmacies that Humana believes are using mail delivery. Humana is basing these terminations on review of claims submitted by pharmacies to Humana. Likely, Humana is comparing
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:
Expect Medicaid Managed Care Plans to Drastically Increase Audits
The Heat is on
Expect increased audit activity in the near future
PAAS expects to see increased audit activity from Medicaid Managed Care Organizations (MCO) across the country. Our predictions include larger numbers of MCO audits, increased scope of audits and new audit strategies. We also believe we will see collaborative audits with coordination between CMS, state Medicaid programs and multiple MCOs working together. Now is the time for you to take proactive measures to audit proof your pharmacy.
PAAS bases these predictions upon the signs coming from the federal government that point toward efforts to push state Medicaid programs to step up program integrity efforts by placing much higher levels of scrutiny on state MCOs. Government reports from the HHS Office of the Inspector and Government Accountability Office published in July, 2018, highlight deficiencies in the states’ oversight of program integrity of their MCOs. These reports conclude that many MCOs are not performing their responsibilities related to the detection, reporting and reduction of fraud, waste and abuse. They are also sure to stimulate CMS to enforce much higher levels of accountability upon states and in turn states to enforce stronger oversight of their MCO plans. CMS will expect state Medicaid agencies to strengthen program integrity with stronger audits, stricter enforcement, corrective action plans and greater overpayment recoveries.
Background
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: