On February 18, 2020, PAAS National® sent an email to all members discussing our revised recommendation: STOP breaking insulin pen boxes. This recommendation came as a result of the FDA-approved product labeling change for insulin pens; effective November 15, 2019.
If you did not receive our email, please see the Stop Breaking Insulin Pen Boxes article from our March 2020 Newsline for more details.
Since that time, we have received many questions from pharmacies regarding this important change. Here are the most common questions: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.
Additional questions answered on the eNewsline:
- Does the pharmacy need to get a new prescription for a larger quantity?
- Can the pharmacy change to insulin vials?
- What if patients cannot afford the copay?
- Can I open the box to label individual pens for LTC facilities?
- Will PBMs recoup on claims where we opened boxes after November 15, 2019?
Authorized Distributors for Diabetic Test Strips
Invoice audits focusing on diabetic test strips are common in the PBM world. PAAS National® believes the PBMs and manufacturers have two purposes for requesting these invoice audits. They are checking for inappropriate billing practices (wrong NDC) and inappropriate sources of inventory (unauthorized distributor).
The newest audit PAAS has seen is coming from manufacturers of test strips that offer rebate contracts with pharmacies for Medicare/Medicaid claims. These audits are very similar to other PBM invoice audits, in that they request invoices from authorized distributors for test strips dispensed during the specified timeframe. Since the manufacturer knows the number of rebates paid, they can easily identify potential shortages. Pharmacies without a valid explanation will be required to repay their rebates and will potentially lose their ability to purchase Medicare/Medicaid-only test strips.
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:
Medicare Part B Requires a Claim Modifier If You Are Not Collecting Patient Signatures!
On March 13, 2020, the Secretary of the Department of Health & Human Services (HHS) authorized waivers under Section 1135 of the Social Security Act to relax certain administrative rules to ease burdens on Medicare providers and suppliers to more easily provide care during the COVID-19 pandemic. The “1135 blanket waivers” include, among other things, waiving the enrollment fee for Medicare B Providers for those pharmacies that want to provide COVID-19 testing and the requirement to obtain patient signatures for proof of delivery for DME Supplies such as diabetic test strips. These waivers are retroactive to March 1, 2020 and are effective until the end of the emergency declaration.
On April 6, 2020, CMS issued Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) and the DME Medicare Administrative Contractors (MACs) issued bulletins in late May explaining that suppliers must include a “CR” modifier and include a narrative of “COVID-19” for claims where patient signatures were not obtained as proof of delivery. Claims that do not include the modifier and narrative may be subject to denial.
Here is an excerpt from the DME MAC joint bulletin:
‘Suppliers should continue to use the appropriate modifiers, including the KX modifier where applicable, for all HCPCS codes included in the NCDs and LCDs listed above. In addition, the CR modifier (CATASTROPHE/DISASTER RELATED) should be added to the HCPCS code(s) billed. Finally, suppliers are instructed to enter “COVID-19” in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 390-BM of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.’
If your pharmacy dispensed DMEPOS items and did not obtain a patient signature as proof of delivery on or after March 1, 2020, then you must 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:
Smartphones Put Pharmacies at Risk for Inappropriate PHI Disclosures
PAAS National®’s Fraud, Waste, and Abuse and HIPAA compliance program updates for 2020 included a new section: 11.11.5 Audio, Video, and Social Media (see our February article FWA/HIPAA Compliance Program Changes for 2020). Smartphone utilization has, unfortunately, become pervasive with patient interactions. Patients on their phone while trying to consult on new medications, or a patient snapchatting a friend while waiting for their prescription to be filled is all too common.
Pharmacies need to developJoin 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:
PAAS Audit Assistance members can view the full article on our eNewsline.
COVID-19 Audit Considerations Follow-Up
On April 3, 2020, PAAS National® sent an urgent email alert to all members discussing COVID-19 audit considerations. This email came as a result of our desire to help pharmacies on the frontlines of this pandemic.
If you did not receive our email, please see the COVID-19 Audit Considerations memo for useful audit tips and guidance to avoid pitfalls. Emails were sent to the email addresses we have on file for your pharmacy and primary contact person. If your pharmacy missed the communication, please call or email us to update your account.
PAAS wants you to stay informed of PBM requirements to help keep your staff, patients, and business safe. Since mid-March, we have been advocating for and tracking reductions, and outright waivers, of specific PBM requirements, most notably:
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:
Caremark Enforcement: Aberrant Quantities & Volumes
PAAS is starting to see Caremark enforce their new policy about Aberrant Quantities and Volume that we first wrote about in a December 2019 article Important: Caremark Provider Manual Updates for 2020!. These notifications state that pharmacies have breached the Provider Agreement and the pharmacy is receiving a formal breach notice as a warning.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:
PBMs Enforcing Return to Stock Policies
It is common practice for PBMs to recoup claims [in full] for medications being picked up after the return to stock timeframes listed in their provider manuals (also known as “unclaimed prescriptions”). Pharmacies with an integrated Point-of-Sale should look to generate a list of prescriptions near the allowed timespan for medications to be left in pick-up bins. PAAS recommends pharmacies implement a procedure to only allow medications to remain for the shortest outlined time – 10 days. If your pharmacy has PAAS National®’s Fraud, Waste & Abuse program, a return to stock policy is available to you, including a log to help you document & complete this task (see section 4.1.1 Unclaimed Prescriptions and Appendix B – Unclaimed Prescription Reversal Log).
Major PBM Return to Stock Timeframes:
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:
Stop Breaking Insulin Pen Boxes– Your Questions Answered
On February 18, 2020, PAAS National® sent an email to all members discussing our revised recommendation: STOP breaking insulin pen boxes. This recommendation came as a result of the FDA-approved product labeling change for insulin pens; effective November 15, 2019.
If you did not receive our email, please see the Stop Breaking Insulin Pen Boxes article from our March 2020 Newsline for more details.
Since that time, we have received many questions from pharmacies regarding this important change. Here are the most common questions: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:
Additional questions answered on the eNewsline:
PBMs Require “Cut Quantity” Documentation
Whenever a pharmacy dispenses a quantity less than what the prescriber ordered, there should be a reason documented for the “cut quantity”. PBMs want to know why the pharmacy is dispensing less than what was prescribed. There are many reasons why this could happen, but the three most common are:
PAAS has seen a few PBMs try to recoup on cut quantities if the pharmacy did not have the reason documented. PAAS Audit Assistance members can view chart of audit discrepancy codes on eNewsline.
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:
COVID-19 Resources
PAAS National® was proud to support you during the PHE for COVID-19 and we want to thank you for your endurance, perseverance, and service to our communities. Due to the PHE ending, resources on this page have changed. Please contact PAAS for the most up-to-date information.
COVID-19 Vaccine Self Attestation
First released 9/27/2021, last updated 8/3/2023
COVID-19 PBM Concessions
First released 5/2020, last updated 5/9/2023
COVID-19 Audit Considerations
First released 4/2020
Medicare and Commercially Insured Patient Request and Attestation for OTC COVID-19 Test Billing
Last updated 4/4/2022
Medicare and Commercially-Insured OTC COVID-19 Tests Frequently Asked Questions (FAQ)
First released 2/2/2022, last updated 4/4/2022
Webinar: PBM FWA Trends and COVID-19 Vaccine Audit Risks
Recorded: 11/18/22
We want to help you stay informed of PBM requirements to help keep your staff, patients, and business safe. The above resources were sent to our members upon the initial release, and members are the first to know any updates, as we are in a consistent evolving state and receiving daily updates from PBMs. Become a PAAS Member Today – call 608-873-1342 or online at PAASNational.com
PBMs will continue to use any technical discrepancy to deny claims on an audit, and these temporary waivers only increase the likelihood that pharmacies will face recoupments. PBMs will be auditing this time period, specifically looking to recoup high dollar claims without supporting documentation – in FULL.
GoodRx Shares Consumer Data
GoodRx, the website and app that has a seemingly endless TV marketing budget, has been sharing their consumer data with Facebook, Google, and others according to a recent article by Consumer Reports. During testing, Consumer Reports found that, “a company could infer highly intimate details about GoodRx users suffering from serious chronic conditions and make educated guesses about their sexual orientation.”
One company that GoodRx has shared consumer information with is Braze, a marketing firm, which claims that the data they collect is only used to target GoodRx users with information and not shared broadly with other advertising companies. GoodRx states Braze is used to send email or text reminders when a consumer is running low on their medication. Another company, Branch, claims it uses GoodRx data to make sure links work correctly in the mobile app.
According to Consumer Reports, both Facebook and Google have denied that they use prescription information to target consumers with ads, especially based on sensitive information like a person’s personal health information. However, Consumer Report’s Digital Lab observed sensitive information being passed to these companies and believes the app and website could be redesigned to prevent it from happening.
The big questions are: Is this legal? Doesn’t HIPAA apply?
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: