Express Scripts Provider Manual – 2023 Updates

All PBMs update their Provider Manuals at regular intervals and Express Scripts (ESI) is no exception. Express Scripts released an updated version of their Provider Manual in January 2023 and provided a “summation of changes” document for network pharmacies that provides a brief description of the changes and where in the Provider Manual the change occurred. Here are important changes that may impact audits:

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  1. Section 5.2 Compliance Checks (revised)
    1. ESI has modified the items that may be requested during a Compliance Check
    2. ESI performs “compliance checks” which are unannounced onsite audits that involve observations of pharmacy to ensure compliance with the contract as well as laws, rules and other regulations. These visits do not include review of prescriptions but notably do review “other pharmacy records” like written policies and procedures and FWA compliance documentation. We have also seen auditors request to see your refrigerator, will-call bins and inventory stock shelves.
  2. Section 5.4 Overbilled Quantity discrepancy (revised)
    1. ESI has modified the definition of the “Overbilled Quantity” discrepancy.
    2. An example of an overbilled quantity could be submitting an incorrect day supply to circumvent a ‘needs prior authorization’ reject message.
    3. A recent audit example was a prescription for diabetic test strips quantity #200 and sig of test 10 times daily and claim rejects when billed as a 20-day supply so pharmacy changes to a 30-day supply to get a paid claim rather than pursue prior authorization.
  3. Section 5.11 Copay Collection (revised)
    1. ESI has added additional language under the Copayment Collection section to specify that they may request check copies, credit card transaction records and point of sale receipts to confirm copay collection.
  4. Section 5.11 Prior Authorization (revised)
    1. Pharmacies that provide assistance to prescribers in completing prior authorizations must have written authorization on file and this documentation is subject to audit review.
  5. Section 5.11 Valid Claim Submission (new)
    1. ESI has added this new section that spells out pharmacy responsibility to ensure that all claims information submitted is accurate and complete and only submitted in accordance with a valid prescription. Claims submitted without a prescription (e.g. “test claims”) may result in recoupment or network termination.
  6. Section 5.12 Fraud, Waste, and Abuse Investigations of Network Providers (new) and Section 5.13 Dispute Resolution for Fraud, Waste, and Abuse Investigations of Network Providers (new)
    1. ESI has added these new sections to differentiate “investigations” from “audits”
    2. PAAS National® often sees multiple rounds of document requests before investigations are concluded
    3. Investigations often include inventory evaluations and outreach to patients or prescribers to corroborate information gathered directly from pharmacy
    4. Pharmacies may appeal final results within 30 days
    5. State audit laws may be more easily circumvented when reviews are labeled as investigations rather than audits

PAAS Tips:

Eric Hartkopf, PharmD