Cybersecurity Incident at Change Healthcare – Documentation is Key to Reducing Audit Risk!

Pharmacies are feeling the impact of the cyber-attack at Change Healthcare resulting in workflow nightmares. PAAS issued an email alert to members about audit risk on 2/23 (details contained herein).  Change Healthcare, a health care technology company that is part of Optum, experienced a cybersecurity issue on February 21, 2024 which is impacting the ability of PBMs, and many healthcare providers nationwide, to process prescriptions through patients’ insurance.

It is not clear, how many partners of Change Healthcare were affected and to what degree. As this continues to further develop, pharmacies can sign up for updates here.

Pharmacies are continuing to fill prescriptions with a change or delay in processing until connections are restored with appropriate controls in place; however, it is important for all pharmacies to be conscious of audit risk.

The following areas represent the greatest audit risk:

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  1. Validity of faxed ‘electronic’ prescriptions
    1. If an e-Rx fails over to fax, that changes the origin of the prescription to fax. In many states, a physical, or digital, prescriber signature is required for faxed prescriptions. If required, be sure to document a call was made to the prescriber’s office for validation.
  2. Refilling claims too soon
    1. Since pharmacies can’t rely on real-time claim rejects, be careful not to refill prescriptions too early.
  3. Proof of delivery in relation to date of service
    1. When rebilling claims, backdate the date of service to the actual date the patient received the medication.
  4. Proof of copay collection
    1. If the copay estimated/billed during the outage is incorrect:
      1. Refund any overpayments to the patient via a trackable method
      2. PAAS recommends the balance of any underpayments be put on a house charge account to document the rationale and potential attempts to collect, as appropriate.

PAAS has shared these concerns with NCPA, who is working diligently with CMS and PCMA to advocate against repercussions and recognize pharmacy sacrifices during this time.

Please feel free to contact us at (608) 873-1342 or should you have additional audit-related questions, PAAS is here to assist.

Trent Thiede, PharmD, MBA