Enhanced FWA Policy & Procedure Customization

Pharmacies often find it challenging to comply with the multitude of state and federal requirements. With you in mind, PAAS National® now offers enhanced customization for community pharmacies within our Fraud, Waste, and Abuse (FWA) and HIPAA Compliance Program that gives pharmacies more control over how their program reflects additional policies and standard operating procedures that may be vital to the pharmacy’s operations.

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!

Join today!

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.

Nominal Gifts  – Safe Harbor Considerations

The practice of Pharmacy is governed by many statutes, regulations, and laws that pharmacy owners and employees must navigate every day. One such law is the Federal Anti-Kickback Statute (AKS), 42 U.S.C. 1320a-7b(b). This law protects federally funded health care programs (and patients) and provides criminal sanctions for those who knowingly and willingly offer, pay, solicit, or receive anything of value to influence or reward business (e.g., referrals). Offering money, or anything of value, to influence a patient’s choice of pharmacy can violate the AKS. For example, if a pharmacy is paid to encourage patients to enroll in a specific Medicare Part D plan, that arrangement would likely be considered an unlawful kickback arrangement.

The AKS does allow certain “gray area” activities laid out by the Office of the Inspector General (OIG) in rulings/opinions referred to as Safe Harbors. A couple examples of safe harbors include…

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!

Join today!

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.

Two Men Accused of $120M Medicare and Medicaid Fraud Using Vulnerable Adults

Last month, PAAS National® wrote about the record-setting $6.8 billion in False Claims Act recoveries in fiscal year 2025. With a continued and expanding focus on fraud enforcement, and strong recoveries in the health care and life sciences, expect an increase in cases the Department of Justice is investigating. In a recent case, two individuals from Queens, NY, were charged with defrauding Medicare and Medicaid by paying illegal kickbacks and bribes, and submitting claims for services that were never provided.

From 2016 to 2026, the two defendants used a pharmacy and two social adult day care centers, meant to help senior citizens, to fraudulently bill Medicare and Medicaid $120 million. The fraud started by luring Medicare patients with illegal cash payments and supermarket gift cards to induce them to fill prescriptions at the defendants’ pharmacy. The same type of illegal cash kickbacks were paid to Medicaid patients to enroll in the social adult day cares owned by the same men. The claims submitted to Medicaid for the day care services often exceeded the permitted capacity of the facilities. 

Some of the healthcare fraud cases PAAS summarizes in our Newsline articles are brazen, extreme cases, but they can also serve as a good reminder to review how you are conducting business. For example, most pharmacies are not giving cash and gift cards to patients for filling prescriptions at their pharmacy, but routinely waiving copays can be another form of an illegal inducement under Anti-Kickback Statutes (and Civil Monetary Penalties Law) and implicate FCA violations. 

PAAS Tips:

Pharmacist Sentenced to 80 Months in Prison

According to a press release from the Department of Justice (DOJ), a Michigan pharmacist was sentenced to 80 months in prison for committing health care fraud. The pharmacist’s scheme consisted of billing health care benefit programs for prescription medications that were ultimately never dispensed. From 2019 through 2022, the pharmacist and his co-conspirator used forged prescriptions from providers to conceal their fraudulent scheme; however, there was no record of these patients ever seeing the prescribers indicated on the forged prescriptions.

Together, these two perpetrators caused over $6 million in losses to health care benefit programs like Medicare, Medicaid, and Blue Cross Blue Shield of Michigan. The pharmacist pleaded guilty to one count of conspiracy to commit health care fraud. In addition to being sentenced 80 months in prison, the pharmacist was ordered to pay $3,889,760 in restitution and $3,230,147 in forfeiture, including his interest in approximately $1.2 million of fraudulent proceeds seized by law enforcement.

PAAS Tips:

  • Only bill a claim pursuant to a valid prescription on file. Billing a “test” claim or “ghost” claim is prohibited by PBMs and those claims, even if reversed, are still subject to audit.
    • Failure to provide a valid hardcopy can raise red flags and lead to accusations of billing false claims
  • For more examples of fraud, waste and abuse, please see our October 2025 Newsline article, Real-World Examples of Fraud, Waste & Abuse and Audit Implications

OIG & DOJ Doubling Down on Health Care Fraud 

The Office of Inspector General (OIG) announced a work plan being initiated for ‘bad actor’ pharmacies (previously identified by CMS or Part D Plan Sponsors) that continue to bill and receive payment for Part D drugs. OIG has concerns that existing CMS enforcement tools, such as revocation, preclusion, and payment suspension, may not effectively deter fraudulent pharmacies from billing Part D plans. The review aims to assess whether pharmacies identified as bad actors continue to bill and receive Part D payments and to identify opportunities for CMS and Part D plan sponsors to strengthen fraud detection and prevention efforts.

Not long after the OIG’s announcement, the U.S. Department of Justice (DOJ) released a report revealing a record-setting $6.8 billion in False Claims Act recoveries in fiscal year 2025. This is the highest annual recovery in the statute’s history, reflecting the intensified enforcement efforts for fighting fraud against the federal government. Health care fraud continues to yield the most recovery in these efforts.

Prescription drugs remained a major focal point, with allegations leading to a nearly $1 billion judgment against a pharmacy. Pharmaceutical manufacturers also faced significant scrutiny, resulting in more than $660 million in settlements tied to alleged copay kickbacks and speaker programs. Additional takeaways from the report include:

  • 1,297 qui tam lawsuits filed by whistleblowers (32% increase from fiscal year 2024 to 2025)
  • 401 investigations opened by the government, 183 involving the health care industry
  • $5.7 billion resulted from health care matters
  • $4.5 billion of the $5.7 billion was recovered through qui tam cases (nearly 79%)
  • Roughly half ($2.27 billion) was recovered in whistleblower health care cases where the government declined to intervene

Notably, self-disclosure and cooperation resulted in several settlements reflecting credits (resulting in reduced payments) for parties who self-reported misconduct, assisted in investigations, and/or implemented remedial measures. The DOJ emphasized its commitment to incentivizing good behavior.

PAAS Tips:

Onsite Audit Preparation – Partial Dispensing Policy

Partially dispensing prescriptions is a common, and practical, approach used in pharmacy practice to ensure patients receive timely access to medications when the full prescribed quantity is not immediately available. Rather than delaying therapy, a pharmacy may dispense a portion of the medication and provide the remaining balance at a later time.

Partial dispensing most often occurs because of inventory shortages, wholesaler delays, or even manufacturer backorders. Regardless of the reason, the pharmacy’s primary goal is to prevent interruptions in therapy, especially for medications that are critical to a patient’s health.

As many independent pharmacies know, onsite audits are often the most stressful, and contentious, audit type. Beyond prescription documentation, auditors are known to ask for various policies and procedures, frequently requesting a partial fill/dispensing policy. Because of the circumstances [of an onsite audit], pharmacies are leery about saying the wrong thing.    

With partial dispensing, …

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!

Join today!

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.

Cybersecurity: System Hardening Guidance

The most recent Office for Civil Rights (OCR) Cybersecurity Newsletter was released in January and focuses on system hardening and protecting electronic PHI (ePHI). “System hardening is the process of customizing electronic information systems (e.g., computer systems and other electronic devices) to reduce their attack surface, thus reducing the number of weaknesses and vulnerabilities that an attacker can exploit.” The following are several suggestions on how to harden your system:

Create Security Baselines – These are minimum standards and settings for servers, smartphones, laptops, desktops, etcetera. throughout your pharmacy. This would include any device that creates, receives, maintains or transmits ePHI. These can include administrative, physical, and technical safeguards.

Patch Known Vulnerabilities – New devices, and devices already in use, can have known vulnerabilities. These vulnerabilities or weaknesses can be exploited by bad actors to gain unauthorized access into your system. It is important to stay up to date on these known vulnerabilities and seek out a way to fix, or ‘patch’, the weakness. Both software (web services, mobile applications, email, etc.) and firmware (specialized software embedded directly into hardware devices to control their basic functions and operations; e.g., firewalls and routers) may need to be patched. Keeping a list of all your information technology (IT) assets is recommended so the type of hardware, software, and security measures are all documented in one convenient location. This makes it easier for the Security Officer to review devices and systems for potential vulnerabilities and recommended patches. Since bad actors are continuously finding new ways to gain entry to systems, it is imperative that these vulnerability checks and patches be conducted routinely.

Remove or Disable Unneeded Software and Services – Devices often come with preloaded software, much of which may not be necessary for the device to function as required within your pharmacy. These unwanted and unused items housed within the device are potentially weak links for bad actors to exploit. Deleting them removes one more potential vulnerability and if a software or service cannot be deleted, disabling it is the next best practice. Also be mindful of ‘admin’ or guest accounts with default passwords. It is recommended that default passwords be updated to a unique, more secure passphrase.

Enable and Configure Security Measures – There may be security measures pre-installed in a device that need to be enabled, or “third-party security solutions such as, for example, anti-malware, endpoint detection and response (EDR), or security information and event management solutions (SIEM).” Examples may include access controls, encryption, audit controls and authentication. Sound familiar? They should! These are examples of technical safeguards as per the HIPAA Security Rule.

Routine evaluation and system hardening is necessary to protect your ePHI. Creating security baselines, patching known vulnerabilities, removing or disabling unneeded software and services and enabling or confirming security measures can be part of this process.

PAAS Tips:

  • Those with a PAAS National® Fraud, Waste & Abuse and HIPAA Compliance Program membership can:
    • Read more about administrative, physical, and technical safeguards in your Policy & Procedure Manual, Sections 11.3 through 11.19.
    • Build and maintain your IT asset list in your online Risk Analysis.
    • Have all staff complete Cybersecurity training. The dynamic nature of cyberthreats necessitates continual adaptation and vigilance. Cybersecurity training helps equip staff with essential knowledge regarding best practices to hinder potential threats related to network connected medical device security, insider data loss, loss or theft of equipment and data, ransomware, and social engineering. Threats lurk around every digital corner and safeguarding sensitive information has never been more crucial.
  • Utilize various methods and resources to help identify vulnerabilities:

Year Two of the Medicare Prescription Payment Plan: Lessons Learned

The first year of the Medicare Payment Prescription Plan (M3P) is over and there was a learning curve for pharmacies and patients alike. It took time for pharmacies to understand the program and what was expected. Along with that, PAAS National® saw new communications from PBMs regarding M3P noncompliance. 

Around May of last year, OptumRx started to send notices to pharmacies regarding “lack of compliance with the M3P requirements, which is a violation of the Agreement.” The pharmacy was then asked to provide a full, detailed response as to their policy and procedure around M3P requirements. Mistakes that were being made ranged from…

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!

Join today!

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.

The Cost of Waiting: Delayed Return to Stock Procedures and Their Hidden Audit Risks

Pharmacies face audit risks in their everyday operations, and staying ahead to protect claims from audit recoupments can be exhausting. PAAS National® analysts continue …

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!

Join today!

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.

Interested in a customized FWA/HIPAA Compliance Policy and Procedure program? Contact PAAS National® at info@paasnational.com or (608) 873-1342 to get started today! 

2026 PAAS 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.

PAAS has implemented changes to ensure pharmacies continue to have a robust program in place. PAAS FWA/HIPAA compliance program members can login to the member portal to view the 2026 FWAC and HIPAA Updates. This year’s updates included:

  • An update to the partial dispensing policy
  • New sections for out-of-stock items, drug recalls and records related to Substance Use Disorder
  • Enhanced content for New York Medicaid (Section 12 and Appendix E, where applicable)
  • Notice of Privacy Practices (NOPP) revisions pursuant to 42 CFR Part 2 updates
  • Civil Money Penalties adjusted for inflation in the training and Program Guide 

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 to add the program for a discounted rate!