# PAAS National

> Helping Community Pharmacies Gain Confidence and Peace of Mind

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## Posts

- [Blog](https://paasnational.com/blog/)
- [Billing Mistakes on Nayzilam and Valtoco Will Cost You!](https://paasnational.com/billing-mistakes-on-nayzilam-and-valtoco-will-cost-you/): Nayzilam is indicated for the acute treatment of intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient's usual seizure pattern (for patients 12 years of age and older), while Valtoco has the same indication for patients 2 years of age and older. They are frequent audit targets... Become an audit assistance
- [2026 DMEPOS Series #6: Ostomy Supplies](https://paasnational.com/2026-dmepos-series-6-ostomy-supplies/): Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements. Medicare Part B suppliers need to be able to produce all the required documentation if audited, and make sure all documentation meets Medicare Part B standards. This DMEPOS series is intended to help you understand these complexities
- [Deciphering the Mystery of Adalimumab’s Unit-of-Measure](https://paasnational.com/deciphering-the-mystery-of-adalimumabs-unit-of-measure/): Humira (adalimumab) is a monoclonal antibody designed to block tumor necrosis factor-alpha (TNF-α), a protein involved in systemic inflammation. It was approved by the FDA in December of 2002 for treating rheumatoid arthritis and was the first fully human monoclonal antibody approved for therapeutic use. Over time, Humira gained additional approvals for the treatment of
- [Zepbound Volume Variability Signals Audit Risk](https://paasnational.com/zepbound-volume-variability-signals-audit-risk/): Claims for Zepbound and other GLP-1 receptor agonists are commonly targeted by auditors. The high claim value paired with their numerous pitfalls make them ‘easy pickings’ for PBMs. Billing a wrong quantity, days’ supply or formulation can put your claims at risk. To make things even more complex, Zepbound has multiple formulations with varying volumes,
- [$2 Billion Telehealth Fraud Case Update: International Ring Members Sentenced](https://paasnational.com/2-billion-telehealth-fraud-case-update-international-ring-members-sentenced/): In December 2024, PAAS National® wrote a Newsline article regarding an international crime ring that found defendants fraudulently billing insurers in a telehealth scheme. On May 19, 2026, one of the defendants was sentenced to 10 years in prison for his participation in the almost $2 billion international health care fraud conspiracy. Two co-defendants were
- [Erroneous Submission Clarification Codes during Short-Cycle Dispensing Are Costing LTC Pharmacies](https://paasnational.com/erroneous-submission-clarification-codes-during-short-cycle-dispensing-are-costing-ltc-pharmacies/): Staring in 2013, CMS required pharmacies dispensing prescription drugs to skilled nursing facilities (SNFs) under Medicare Part D (including Medicare Advantage plans) to dispense solid oral doses of brand-name medications in no greater than 14-day increments through regulation referred to as “short-cycle dispensing” (SCD). This applies to all solid oral brand name drugs except: (1)
- [Practical Tips for Safeguarding Transferred Prescriptions](https://paasnational.com/practical-tips-for-safeguarding-transferred-prescriptions/): Prescriptions transferred into your pharmacy, especially for high-cost medications, should be thoroughly reviewed for completeness, as missing or incomplete elements can quickly become a costly audit risk. Transferred prescriptions are common audit targets because origin code 5 makes them easy for auditors to identify, and auditors know these prescriptions require additional supporting documentation. Just one
- [Creating Effective Corrective Action Plans for Future Success](https://paasnational.com/creating-effective-corrective-action-plans-for-future-success/): PAAS National® analysts regularly assist pharmacies that need to perform a Root Cause Analysis and/or Corrective Action Plan (CAP) due to high dollar audit recoupments or other major discrepancies (e.g., inventory shortages). These significant results can trigger further consequences such as additional audits, payment suspension and/or the threat of network termination. CAPs are intended to
- [2026 DMEPOS Series #5: Immunosuppressive Drugs for Transplant](https://paasnational.com/2026-dmepos-series-5-immunosuppressive-drugs-for-transplant/): Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the strenuous documentation requirements. Medicare Part B suppliers need to be able to produce all the required documentation if audited, and make sure all documentation meets Medicare Part B standards. This DMEPOS series is intended to help you understand these complexities
- [The Workflow Mistake That Could Cost Your Pharmacy Dearly!](https://paasnational.com/the-workflow-mistake-that-could-cost-your-pharmacy-dearly/): Pharmacy staff are constantly balancing patient care with insurance requirements. While pharmacies may face pressure to provide medications quickly, bypassing... 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
- [West Coast Strike Force Launched to Target Health Care Fraud](https://paasnational.com/west-coast-strike-force-launched-to-target-health-care-fraud/): The U.S. Department of Justice has announced a new West Coast Health Care Fraud Strike Force focused on investigating and prosecuting health care fraud in Arizona, Nevada, and Northern California. The initiative brings together federal prosecutors and agencies including the DOJ, FBI, DEA, and HHS-OIG to aggressively target fraud involving Medicare, Medicaid, TRICARE, and private
- [Low-Income Subsidy (LIS) Dual-Eligible Copay Reconciliation](https://paasnational.com/low-income-subsidy-lis-dual-eligible-copay-reconciliation/): PAAS National® analysts have recently assisted numerous pharmacies with letters from PBMs regarding copays for medications dispensed to dual eligible (Medicare Part D and Medicaid) patients within the last few months. 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
- [Alert! – Shingrix Billing Quantity Update](https://paasnational.com/alert-shingrix-billing-quantity-update/): PAAS National® continues to review audits for Shingrix, a vaccine indicated for prevention of herpes zoster (shingles) in adults over 50 years of age (and certain immunosuppressed adults over 19). These audits appear to have been triggered by... Become an audit assistance member today to continue reading this article. As a member, you’ll have access
- [Billing Alcohol Swabs? Avoid These Pitfalls!](https://paasnational.com/billing-alcohol-swabs-avoid-these-pitfalls/): PAAS National® continues to see audits for alcohol swabs. While billing for alcohol swabs often seems trivial, there can be confusion when these claims may be covered under the Medicare Part D or Medicare Part B benefit. Claim recoupments stemming from billing to the wrong benefit are common. Alcohol swabs are only covered under Part
- [Keep Continuous Glucose Monitor (CGM) Billing Straight](https://paasnational.com/keep-continuous-glucose-monitor-cgm-billing-straight/): There are continuous developments in the CGM space, with new products, and changing replacement schedules, emerging that pharmacies must be aware of. For example, Dexcom released the Dexcom G7 15-Day Sensor last December. The new product features a longer wear time (up to 15.5 days – with a 12-hour grace period), improved accuracy, and a
- [Is a Response to the NADAC Survey Required?](https://paasnational.com/is-a-response-to-the-nadac-survey-required/): The National Average Drug Acquisition Cost (NADAC) Survey has been around for over a decade, but some pharmacies have never received this survey request before. Consequently, PAAS National® is frequently contacted for information and guidance. Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of
- [Titration Trouble: Dispensing Initiation and Maintenance Prescriptions Together](https://paasnational.com/titration-trouble-dispensing-initiation-and-maintenance-prescriptions-together/): Titration prescriptions are a common target for PBMs seeking to recoup claims, often citing “overutilization,” “refill too soon,” “therapeutic duplication,” or “clinical misuse.” While billing two separate prescription numbers (and/or NDCs) may allow both claims to adjudicate on the same day, plans typically expect... Become an audit assistance member today to continue reading this article.
- [Schedule II Partial Fills: Eligibility and Documentation](https://paasnational.com/schedule-ii-partial-fills-eligibility-and-documentation/): There are numerous reasons why a Schedule II controlled substance (C-II) may be partially filled. Understanding the rationale behind the partial fill is necessary to ensure: (1) the authorization to partial fill is valid and (2) appropriate documentation is maintained pursuant to State and Federal Laws, such as 21 CFR 1306.13. There are three major
- [Appropriate DUR Documentation Can Prevent Audit Recoupments](https://paasnational.com/appropriate-dur-documentation-can-prevent-audit-recoupments/): As PBMs audits continue to evolve and aggressively pursue recoupments, PAAS National® continues to see audits that scrutinize beyond general prescription information. When preparing the documentation requested in an audit, it is important to review more than what is on the face of the hard copy and prescription label. DUR (Drug Utilization Review) override documentation
- [Hidden Risks in Online Marketplace Drug Purchasing: What Pharmacies Need to Know](https://paasnational.com/hidden-risks-in-online-marketplace-drug-purchasing-what-pharmacies-need-to-know/): The rise of online pharmaceutical marketplaces has introduced new efficiencies for pharmacies seeking to manage inventory, control costs, and address drug shortages. These platforms often promise competitive pricing, expanded sourcing options, and rapid fulfillment. However, they also introduce a significant, and often underappreciated, risk: the potential for suspect or counterfeit product entering the pharmacy supply
- [Test Your Knowledge – Take the PAAS Newsline Quiz!](https://paasnational.com/test-your-knowledge-take-the-paas-newsline-quiz/): Staying audit-ready isn’t just about reading the latest guidance – it’s about understanding how it applies to your day-to-day pharmacy operations. That’s why PAAS National® has launched a new eNewsline Quiz, designed to help pharmacy employees reinforce key takeaways from each Newsline article and ensure the pharmacy is getting the most value from their membership.
- [PBM Questionnaires Sent to Patients and Prescribers Signal Trouble Ahead](https://paasnational.com/pbm-questionnaires-sent-to-patients-and-prescribers-signal-trouble-ahead/): PBMs utilize many different strategies to evaluate the legitimacy of pharmacy claims. Desk, onsite, and invoice audits are traditionally performed, but sometimes auditors will expand their investigation outside of pharmacy-provided documents to further validate the claims. Occasionally, PBMs will send questionnaires to patients (and even prescribers) to confirm valid patient-prescriber-pharmacy relationships. These questionnaires are typically
- [Enhanced FWA Policy & Procedure Customization](https://paasnational.com/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
- [Nominal Gifts  – Safe Harbor Considerations](https://paasnational.com/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,
- [Dispensing Less than Prescribed? Documentation is Key!](https://paasnational.com/dispensing-less-than-prescribed-documentation-is-key/): Pharmacies often need to adjust the quantity being dispensed from what was originally prescribed. While there are a multitude of reasons these changes might be necessary, the rationale may be closely scrutinized during an audit. Auditors will look for documentation to justify any deviation from the originally prescribed quantity; missing (or inadequate) documentation can lead
- [2026 DMEPOS Series #4: Continuous Glucose Monitors](https://paasnational.com/2026-dmepos-series-4-continuous-glucose-monitors/): Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) present an opportunity for pharmacies to expand patient care—but they also come with a distinct, and often misunderstood, set of regulatory requirements. Unlike traditional prescription dispensing, DMEPOS items are subject to strict documentation standards, supplier enrollment rules, and billing nuances that are frequently targeted in audits. Pharmacies
- [Advance Beneficiary Notice of Noncoverage – What You Need to Know](https://paasnational.com/advance-beneficiary-notice-of-noncoverage-what-you-need-to-know/): The Advance Beneficiary Notice of Noncoverage (ABN) is a written notice that DME suppliers may give to a Medicare beneficiary before providing an item or service when the supplier has reason to believe that Medicare will deny paying for the item (or service). The ABN allows the beneficiary to make an informed decision as to
- [Two NDCs, One Fill: Best Practices for Pharmacies  ](https://paasnational.com/two-ndcs-one-fill-best-practices-for-pharmacies/): Pharmacies frequently find themselves piecing together a prescription using leftover inventory from an old NDC and a new [equivalent] NDC to finish the fill—often due to wholesaler preferred status changes, drug availability, discontinued products, or changing purchasing preferences. Using two NDCs on a single prescription introduces significant dispensing and billing risks, and if not handled
- [Ozempic Prescriptions Continue to Wreak Havoc on Audit Results](https://paasnational.com/ozempic-prescriptions-continue-to-wreak-havoc-on-audit-results/): Pharmacies know Ozempic® prescriptions have been on PBM radars since they were first released. Not only are these high dollar claims, but they are an easy target for incorrect billing. Making a simple days’ supply error on an Ozempic® claim can result in thousands of dollars being recouped. Become an audit assistance member today to
- [PBM Audit Risk When Purchasing Inventory from a Closing Pharmacy](https://paasnational.com/pbm-audit-risk-when-purchasing-inventory-from-a-closing-pharmacy/): When a pharmacy purchases remaining prescription drug inventory from a closing pharmacy, what may seem like a straightforward transaction can introduce complex documentation gaps and challenges—ultimately increasing exposures to downstream PBM audit risk. While such transfers are often permissible under state law and the Drug Supply Chain Security Act (DSCSA), PBM auditors frequently scrutinize non-wholesaler
- [Having an NDC Does Not Mean FDA Approved](https://paasnational.com/having-an-ndc-does-not-mean-fda-approved/): The first step in getting a new manufacturer/product on the market starts with a manufacturer, repackager, or distributor registering with the FDA to obtain a labeler code (the first set of numbers in the NDC). Once the labeler code is obtained, the company then assigns the product code (middle set of numbers in the NDC)
- [How to Stay Prepared for an Invoice Audit](https://paasnational.com/how-to-stay-prepared-for-an-invoice-audit/): PAAS National® has seen invoice audits double in the last five years, a trend that has sparked widespread discussion from community pharmacy owners. Invoice audits are frequently categorized as “investigational” and used to identify pharmacies not purchasing from appropriate sources and/or potentially false (or phantom) claims. Auditors will act like an accountant by reviewing the
- [CGM Claims Under the Microscope](https://paasnational.com/cgm-claims-under-the-microscope/): Audits from CMS through the Supplemental Medical Review Contractor (SMRC) are rolling in at high volume for continuous glucose monitors (CGMs), HCPCS E2103. The goal of SMRC is to help lower improper payment rates by conducting nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claim to determine whether claims follow coverage, coding, payment,
- [Will Your DAW 1 Documentation PAAS an Audit?](https://paasnational.com/will-your-daw-1-documentation-paas-an-audit/): PAAS National® audit analysts have the privilege of assisting pharmacies in all 50 states, DC, Puerto Rico and the Virgin Islands. With the DOJ expanding Health Care Fraud units, pharmacies should expect increased monitoring on Medicare and Medicaid programs targeting FWA, state law violations and program compliance. If you haven’t... Become an audit assistance member
- [Ensuring Audit Success: Proof of Delivery for Mailed Prescriptions](https://paasnational.com/ensuring-audit-success-proof-of-delivery-for-mailed-prescriptions/): PBM contracts require pharmacies to obtain evidence that demonstrates prescriptions were received by patients, ensuring claims are not falsely submitted for reimbursement. In community pharmacies, a patient typically signs a log when picking up their medication at the pharmacy (or upon delivery). What happens if the prescription is mailed to the patient? Become an audit
- [Two Men Accused of $120M Medicare and Medicaid Fraud Using Vulnerable Adults](https://paasnational.com/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
- [Prior Authorization Support: Strategies to Mitigate Audit Risks](https://paasnational.com/prior-authorization-support-strategies-to-mitigate-audit-risks/): Prior authorization (PA) requirements imposed by PBMs have become a major administrative barrier to medication access. To help reduce delays and improve patient outcomes, some pharmacies are assisting prescribers by submitting prior authorizations on their behalf. While these services can benefit patients and strengthen relationships between pharmacies and prescribers, they also introduce important compliance and
- [DMEPOS Series #3: Nebulizer Solution Claims](https://paasnational.com/dmepos-series-3-nebulizer-solution-claims/): Billing Medicare B is not easy. The Local Coverage Determinations (LCD) and associated Policy Articles (PA) for each DMEPOS category, along with the Standard Documentation Requirements for All Claims Submitted to DME MACs, are filled with billing and documentation guidelines which suppliers must fully comprehend and follow to avoid claim chargeback. The PAAS National 2026
- [Are You Meeting CMS Standards for LTC Pharmacy at Home?](https://paasnational.com/are-you-meeting-cms-standards-for-ltc-pharmacy-at-home/): Retail pharmacies exploring the option to provide long-term care pharmacy services at home must be aware of additional requirements that apply. In 2005, CMS provided guidance to Part D plans on requirements for performance and service criteria regarding pharmacies servicing LTC facilities. More recently, this guidance has been applicable to pharmacies servicing LTC Pharmacy at
- [New DUR Codes Clarify Medicare Part B or D for Tetanus, Hepatitis A/B and Rabies Vaccines](https://paasnational.com/new-dur-codes-clarify-medicare-part-b-or-d-for-tetanus-hepatitis-a-b-and-rabies-vaccines/): Tetanus, Hepatitis A/B and Rabies vaccines may be covered by either Medicare Part B or Part D. Coverage typically depends on the vaccine’s purpose: 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
- [How to Avoid the Vaginal Cream Recoupment Domino Effect](https://paasnational.com/how-to-avoid-the-vaginal-cream-recoupment-domino-effect/): Estrace® and Premarin® vaginal creams continue to be audit targets because they are often found to be billed incorrectly. A recovery on one claim billed with a wrong days’ supply often causes subsequent refills to be recouped for being ‘refilled too soon’. To prevent this claim recoupment... Become an audit assistance member today to continue
- [Pharmacist Sentenced to 80 Months in Prison](https://paasnational.com/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
- [Preventing Substitution Errors Among Interchangeable Denosumab Biosimilars](https://paasnational.com/preventing-substitution-errors-among-interchangeable-denosumab-biosimilars/): Many pharmacies are familiar with Prolia® (denosumab) for the treatment of osteoporosis in women after menopause who are high risk for fracture or cannot use another osteoporosis medication (or the other medications weren’t efficacious). There is another denosumab product (brand name Xgeva®) approved for bone problems due to cancer. Prolia® and Xgeva® are not ...
- [Isotretinoin Therapeutic Equivalence and iPLEDGE® REMS Documentation Alert](https://paasnational.com/isotretinoin-therapeutic-equivalence-and-ipledge-rems-documentation-alert/): According to the FDA labeling, isotretinoin capsules are indicated for the treatment of severe recalcitrant nodular acne in non-pregnant patients 12 years of age and older with multiple inflammatory nodules with a diameter of 5 mm or greater. Become an audit assistance member today to continue reading this article. As a member, you’ll have access
- [Improving Accuracy and Efficiency: Rx Days’ Supply Calculator Adoption Grows](https://paasnational.com/improving-accuracy-and-efficiency-rx-days-supply-calculator-adoption-grows/): Nearly one thousand pharmacy professionals now rely on the Rx Days’ Supply Calculator to help address the ongoing challenges of manually calculating the appropriate quantity or days’ supply of medications, saving time and reducing errors while simultaneously decreasing the risk of PBM audits. The Rx Days’ Supply Calculator app is a tool designed to simplify
- [Creon Claims at Risk: OptumRx Audit Recoupments Continue](https://paasnational.com/creon-claims-at-risk-optumrx-audit-recoupments-continue/): OptumRx continues to focus on medications with special dispensing requirements. Creon® has ranked among the top five medications requested through OptumRx prescription validation requests for the past three years and that trend is continuing into 2026. Although the PBM characterizes these reviews as prescription validation requests rather than desk audits, PAAS National® analysts consistently see
- [Diabetic Test Strip Authorized Distributors](https://paasnational.com/diabetic-test-strip-authorized-distributors-2/): Independent pharmacies continue to receive threatening letters regarding the purchase of LifeScan OneTouch® test strips. 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
- [OIG & DOJ Doubling Down on Health Care Fraud ](https://paasnational.com/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
- [DMEPOS Updates: Annual Reaccreditation Surveys, New Site Visit Service Contractors](https://paasnational.com/dmepos-updates-annual-reaccreditation-surveys-new-site-visit-service-contractors/): PAAS National® wants to alert members to a few recent changes that may impact pharmacies who are dispensing DMEPOS supplies to Medicare patients. 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
- [Onsite Audit Preparation – Partial Dispensing Policy](https://paasnational.com/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
- [2026 DMEPOS Series #2: Urological Supplies](https://paasnational.com/2026-dmepos-series-2-urological-supplies/): Understanding Medicare Part B documentation requirements can be difficult. Local Coverage Determinations and associated Policy Articles for each DMEPOS category, along with the Standard Documentation Requirements for All Claims Submitted to DME MACs, are filled with billing and documentation guidelines which suppliers must fully comprehend and follow to avoid claim chargebacks. The PAAS National® 2026 DMEPOS Series is
- [Cybersecurity: System Hardening Guidance](https://paasnational.com/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
- [U.S. House Judiciary Committee Releases Scathing Report on CVS Health](https://paasnational.com/u-s-house-judiciary-committee-releases-scathing-report-on-cvs-health/): The U.S. House Committee on the Judiciary and its Subcommittee on the Administrative State, Regulatory Reform, and Antitrust, released an interim staff report titled: “When CVS Writes the Rules: How CVS Protects Itself from Innovation and Competition”. The report outlines evidence that CVS Health [and CVS Caremark] engaged in a multi‑year strategy to suppress competition
- [Download the New Medicare Prescription Payment Plan Likely to Benefit Notice (CMS Form 10882)](https://paasnational.com/download-the-new-medicare-prescription-payment-plan-likely-to-benefit-notice-cms-form-10882/): As a quick reminder, CMS Form 10882 is a Medicare notice that Plan Sponsors (via CMS directive) require pharmacies to provide patients if a prescription copay for a Medicare Part D claim exceeds $600. The requirement to distribute CMS Form 10882 started January 1, 2025, and is prompted by an Approval Message Code 056. The
- [Top Ten Newsline Articles for 2025](https://paasnational.com/top-ten-newsline-articles-for-2025/): In today’s fast-paced world, it’s crucial to stay informed with the latest insights to avoid putting your pharmacy at risk, making continuous education vital. Mailed to pharmacies with the January Newsline, this article lists the top ten PAAS National® Newsline articles from 2025: The NEW Inventory Transfer Log and Why it Could Save You Big!
- [2026 DMEPOS Series #1: Standard Documentation Requirements](https://paasnational.com/2026-dmepos-series-1-standard-documentation-requirements/): Many pharmacies struggle with Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) audits due to the complexity in medical billing and the onerous documentation requirements. To help you alleviate those challenges, PAAS is starting a new DMEPOS series. The series is intended to help you understand these complexities and be sure you have valid, supporting
- [Medicare Transaction Facilitator (MTF) Updates](https://paasnational.com/medicare-transaction-facilitator-mtf-updates/): We are now one month into 2026, and pharmacies are feeling the impact of the Medicare Part D Drug Price Negotiation Program (MDPNP). Hopefully your pharmacy is getting more comfortable ... 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
- [Year Two of the Medicare Prescription Payment Plan: Lessons Learned](https://paasnational.com/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
- [The Price of Bypassing Plan Limit Rejections](https://paasnational.com/the-price-of-bypassing-plan-limit-rejections/): PAAS National® continues to see audits being flagged with “Bypassing Plan Limits”. When billing claims, it is very important to pay close attention to these rejection messages, as ignoring them could cost you during an audit. There are several reasons why a pharmacy may see this discrepancy in an audit, including: Become an audit assistance
- [$300,000 Settlement for Employing Excluded Individual](https://paasnational.com/300000-settlement-for-employing-excluded-individual/): The U.S. Attorney’s Office for the District of New Hampshire recently announced a $300,000 settlement with a telehealth company and its owner to resolve allegations of improper Medicaid billing under the False Claims Act. The government alleged that the company billed Medicaid for services provided by an individual who was excluded from participation in federal
- [Prescriber Statements Made Simple](https://paasnational.com/prescriber-statements-made-simple/): Several audit discrepancies can be resolved by obtaining a letter from the prescriber clarifying their intentions for a prescription they wrote. While PAAS National® often gets requests for a template/form letter, this is problematic and impractical (except for Humana). PBMs have their own requirements and no two prescribers would write their letters using the same
- [Two Liraglutide Products That Are NOT Therapeutically Equivalent?](https://paasnational.com/two-liraglutide-products-that-are-not-therapeutically-equivalent/): PAAS National® alerted pharmacies to the launch of the first ‘generic’ GLP-1 receptor agonist, liraglutide, back in late June 2024. The product released was an Authorized Generic (AG) of Victoza®. In August 2025, another liraglutide product was approved and released to the market as an Abbreviated New Drug Application (ANDA) of Saxenda®. With this release
- [The Cost of Waiting: Delayed Return to Stock Procedures and Their Hidden Audit Risks](https://paasnational.com/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
- [Notable Updates From the 2026 CVS Caremark Provider Manual  ](https://paasnational.com/notable-updates-from-the-2026-cvs-caremark-provider-manual/): CVS Caremark updates, and mails, their complete provider manual in a hardcopy version to member pharmacies every other year, on even years. Pharmacies should have received a printed copy of the 2026 Caremark Provider Manual towards the end of last year. Undoubtedly due to congressional pressure, and as discussed in this month’s feature Newsline article:
- [340B Claim Identification Requirements](https://paasnational.com/340b-claim-identification-requirements/): As part of the NCPA 340B task force, PAAS National® has advocated strongly that pharmacies should not be required to identify 340B claims. The individual claim’s status is typically unknown at the point of sale, and the process to update claims (N1 information exchange transactions), or reverse and rebill, is arduous. Not only is it
- [Caremark Rx Claim Review - Is This Trouble for My Pharmacy?](https://paasnational.com/caremark-rx-claim-review-is-this-trouble-for-my-pharmacy/): Pharmacies have sent PAAS National® notices from Caremark entitled “CVS Caremark Rx Claim Review.” The first line of the notice says, “This communication is for educational purposes only and is not part of an audit.” This has led to many questions and confusion amongst the pharmacies receiving these notices. PAAS has seen waves of these
- [New Year, Same Routine: Tips for Ensuring Accurate Billing](https://paasnational.com/new-year-same-routine-tips-for-ensuring-accurate-billing/): For pharmacies, the new year is often hectic. PAAS National® is here to help make your transition into the new year less stressful by highlighting important billing considerations and tips. 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
- [OIG Report: Medicare Payments for Continuous Glucose Monitors](https://paasnational.com/oig-report-medicare-payments-for-continuous-glucose-monitors/): A recent OIG report found that Medicare may be overpaying suppliers for Continuous Glucose Monitors (CGMs) and supplies relative to other payers. The report highlighted the following: Medicare Part B payments have increased dramatically from $109 million in 2018 to $1.3 billion in 2023 Medicare payments for CGM supplies exceeded supplier acquisition costs by $359
- [$37.76 Million CVS Insulin Pen Case Settled](https://paasnational.com/37-76-million-cvs-insulin-pen-case-settled/): Last month we wrote an article entitled: Guidelines for Dispensing Insulin Pens in their Original Carton. A few days later, the Office of Inspector General (OIG) announced that CVS had agreed to a $37.76 million settlement for violations of the False Claims Act by over-dispensing insulin pens between 2010 and 2020. Investigators found that Medicare,
- [Eye Drop Chart Updates](https://paasnational.com/eye-drop-chart-updates/): PAAS National® analysts have identified a recent trend of audit enforcement related to days’ supply for eye drops, with a particular focus from Prime Therapeutics. Most PBMs provide a “drops per mL” estimate in their provider manual, but they often provide a qualifier that pharmacies should use the PBM estimate “unless otherwise indicated by the
- [Splitting Suboxone® Can Lead to Audit Recoupments](https://paasnational.com/splitting-suboxone-can-lead-to-audit-recoupments/): PAAS National® has noticed an uptick in audit recoupments for Suboxone® claims where the patient instructions were to split the films or tablets. Notably, OptumRx has a renewed focused on these claims and has been citing them as... Become an audit assistance member today to continue reading this article. As a member, you’ll have access
- [2026 PAAS Fraud, Waste & Abuse and HIPAA Compliance Program Updates](https://paasnational.com/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
- [The Audit Risk at The Tips of Your Fingers (and Toes!)  ](https://paasnational.com/the-audit-risk-at-the-tips-of-your-fingers-and-toes/): Antifungal nail treatments remain a high audit target. If the pharmacy is dispensing Jublia® (efinaconazole), ciclopirox (formerly Penlac®), or tavaborole (formerly Kerydin®), you can almost guarantee you’ll see that claim show up on an audit. Auditors love these medications because if the prescription does not clearly indicate... Become an audit assistance member today to continue
- [2025 PBM Prescription Validation Requests Summary](https://paasnational.com/2025-pbm-prescription-validation-requests-summary/): PAAS National® saw the number of validation requests/claim reviews increase 22% in 2025. While OptumRx® sends out most of the validation requests/claim reviews, we also see them from Caremark, Express Scripts, Humana, MagellanRx, Medimpact, and Prime Therapeutics. Three additional PBMs began to do the reviews in 2025 and those are Meridian, Pharmastar and some Medicaid
- [Understanding Albuterol HFA Inhaler Substitution](https://paasnational.com/understanding-albuterol-hfa-inhaler-substitution/): PAAS National® analysts have repeatedly seen auditors targeting claims with potentially undocumented substitution issues. Albuterol HFA inhalers are one of the top products [incorrectly] substituted that can lead to claim recoupment. Pharmacies should utilize the chart and PAAS Tips below to better understand pharmacy level substitution of Albuterol HFA inhalers to reduce the risk of
- [The True Cost of Invoice Audits and Shortages](https://paasnational.com/the-true-cost-of-invoice-audits-and-shortages/): Analysts at PAAS National® assist with invoice audits on a daily basis. While not as common (in number) as desk audits, the implications of bad audit results are high and can be challenging to appeal. Often questions come up asking why it matters if the exact NDC is billed? A few recent cases from the
- [Reap the Benefits of the PAAS National® Newsline Archive](https://paasnational.com/reap-the-benefits-of-the-paas-national-newsline-archive-2/): Did you know that you can save time by searching past Newsline articles to find answers to your common questions? In fact, the Newsline archive offers articles going back to 2016! The search feature makes it simple to find that one article you know you read a while ago, but can’t seem to remember what
- [Medicare Drug Price Negotiation: MTF Data Module Enrollment & Caremark Attestation](https://paasnational.com/medicare-drug-price-negotiation-mtf-data-module-enrollment-caremark-attestation/): Starting in 2026, Medicare has negotiated the price of 10 brand drugs under the Medicare Drug Price Negotiation Program as part of the Inflation Reduction Act of 2022. The negotiations between CMS and drug manufacturers have resulted in Maximum Fair Prices (MFPs). To implement this program, CMS has created the Medicare Transaction Facilitator (MTF) which
- [Let PAAS National® Help You: Tips for a Faster, More Accurate Audit Review](https://paasnational.com/let-paas-national-help-you-tips-for-a-faster-more-accurate-audit-review/): PAAS National® analysts strive to assist pharmacies in providing accurate and efficient responses during the documentation review process for an audit. It is helpful for analysts to have simultaneous access to both the prescription and billing information, as the audit review is conducted in a manner consistent with remote verification practices. PAAS recommends submitting your
- [Can I Shred This Yet? Requirements for Record Retention](https://paasnational.com/can-i-shred-this-yet-requirements-for-record-retention/): Record retention is an important topic pharmacies need to be on top of to ensure compliance. Although a large majority of prescriptions filled by pharmacies are now electronic, other methods such as telephone orders, transfers, faxes, and written hard copies have not been completely wiped from practice. It’s understandable that a pharmacy may be looking
- [Buying in Bulk Can Cost You Down the Road](https://paasnational.com/buying-in-bulk-can-cost-you-down-the-road/): For independent pharmacies, invoice audits continue to gain traction by the PBMs. While the recently announced WAC decreases make bulk purchasing a potentially precarious scenario, one PBMs also has rigid requirements for “bulk purchasing”. Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles
- [HIPAA Breach in 2025? Notification to HHS is Required](https://paasnational.com/hipaa-breach-in-2025-notification-to-hhs-is-required/): What is significant about March 1, 2026? According to the website Days Of The Year, it is National Barista Day, Share a Smile Day, and Endometriosis Awareness Day. While these are all great causes, the date carries additional significance for any covered entity (e.g., a pharmacy) who had a HIPAA breach of less than 500
- [Avoiding TPE Audit Denials: Guidance for Medicare Part B Nebulizer Solution Claims](https://paasnational.com/avoiding-tpe-audit-denials-guidance-for-medicare-part-b-nebulizer-solution-claims/): Recently, PAAS National® analysts have been assisting pharmacies with Targeted Probe and Educate (TPE) audits from CGS, the DME Medicare Administrative Contractor (MAC) for Jurisdictions B and C. Per CGS, “The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and
- [Lessen Your Headache When It Comes to Migraine Medications - New PAAS Resource!](https://paasnational.com/lessen-your-headache-when-it-comes-to-migraine-medications-new-paas-resource/): Over the past few years, the number of medications available and prescribed for migraine prevention and treatment has notably increased, which leads to additional audit risks. PBMs continue to monitor and audit migraine medications due to their high cost, often incalculable instructions and common billing errors. Our PAAS National® analyst team wants to help you
- [DEA Suffixes: A Quick Reference for Pharmacists](https://paasnational.com/dea-suffixes-a-quick-reference-for-pharmacists/): According to 21 CFR 1306.03, a prescriber must be authorized to prescribe controlled substances in the place they are licensed to practice and must either be registered with the DEA or exempted from registration (typically reserved for officials of the U.S. Army, Navy, Marine Corps, Air Force, Space Force, Coast Guard, Public Health Service, or
- [OIG Report: $22.7 Million in Improper Payments for DMEPOS During Inpatient Stays](https://paasnational.com/oig-report-22-7-million-in-improper-payments-for-dmepos-during-inpatient-stays/): The Office of Inspector General (OIG) recently released a report outlining $22.7 million in improper payments from 2018-2024 for DMEPOS provided during inpatient stays. This was a follow up to a previous report issued in 2018 that found over $34 million in improper payments from 2015-2017. The CMS identified system edits that were not working
- [Understanding Audit Risk with Insulin Prescriptions](https://paasnational.com/understanding-audit-risk-with-insulin-prescriptions/): Keeping up with all the new insulin products has become a full-time job. The range of delivery devices and concentrations continues to expand. Pharmacies need to stay informed about these updates to ensure their prescriptions meet audit requirements. Recently, PBMs have flagged insulin prescriptions as ... Become an audit assistance member today to continue reading
- [Guidelines for Dispensing Insulin Pens in their Original Carton](https://paasnational.com/guidelines-for-dispensing-insulin-pens-in-their-original-carton/): In 2019, the FDA required new labeling for insulin pen packages that states, “Dispense in this sealed carton”. The rationale was pursuant to a Tracked Safety Issue which cited concerns for dispensing errors, counterfeit product and failure to include the patient instructions for use with each dispensing. Since that time, PAAS National® has recommended ...
- [Days’ Supply Rejections on Unbreakable Packages](https://paasnational.com/days-supply-rejections-on-unbreakable-packages/): PAAS National® analysts continue to see unbreakable packages on audits causing recoupment due to dispensing quantity and days’ supply issues. Below is a list of common scenarios: Dispensing quantities outside of a full package size for an unbreakable package Overbilling multiple unbreakable packages Refilling claims too soon when billing for a single unbreakable package that
- [Do Not Let Santyl® Cause a Wound in Your Pocket](https://paasnational.com/do-not-let-santyl-cause-a-wound-in-your-pocket/): Santyl® ointment is a high dollar topical medication with specific instructions for application which carries high audit risk and potential recoupment from your pocket. Pharmacies need to follow the guidance below to help reduce their audit risk. Become an audit assistance member today to continue reading this article. As a member, you’ll have access to
- [Evaluating the Days’ Supply of Migraine Medications](https://paasnational.com/evaluating-the-days-supply-of-migraine-medications/): PAAS National® analysts continue to see as needed migraine medications undergo increased scrutiny during audits, and unfortunately, the auditors are (too often) successful in their recoupment efforts. 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
- [Are You Getting the Most from Your PAAS National® Membership?](https://paasnational.com/are-you-getting-the-most-from-your-paas-national-membership/): While PAAS National® may be known for our best-in-class, hands-on audit assistance, we also offer insightful and educational information and resources that you may be missing out on! Below is a list of resources found in the Audit Assistance section of the Member Portal that could help ensure you and your pharmacy staff stay educated
- [DOJ Expands Health Care Fraud Units: What It Means for Pharmacies](https://paasnational.com/doj-expands-health-care-fraud-units-what-it-means-for-pharmacies/)
- [Why Copays for Pharmacy Staff Should NOT Be Waived](https://paasnational.com/why-copays-for-pharmacy-staff-should-not-be-waived/): Successful pharmacies recognize the immense value of team members who are dedicated, diligent, knowledgeable, and reliable. With the financial squeeze in community pharmacies, payroll can be a tough spot to spend extra money. Having the employee fill prescriptions at the pharmacy they work in, and not having them pay the resulting copay, can be a
- [Pitfalls with the Most Common DAW Codes Billed](https://paasnational.com/pitfalls-with-the-most-common-daw-codes-billed/): PBMs and audit companies pay close attention to how pharmacies bill claims, including which DAW code was used. This seemingly innocent billing element can cause significant audit issues if not used properly. Any DAW (other than 0) should have supporting documentation for why it was appropriate to use. PBMs will continue to pay close attention
- [AstraZeneca/Farxiga® Letters—Round 2 Hitting Pharmacies](https://paasnational.com/astrazeneca-farxiga-letters-round-2-hitting-pharmacies/): Pharmacies across the country are receiving a second notice from AstraZeneca regarding Farxiga® discrepancies. As before, there are two versions of this letter but now AstraZeneca is asking pharmacies for specific information and actions. Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles
- [Retail Playbook in LTC Audits: More Alike Than Different](https://paasnational.com/retail-playbook-in-ltc-audits-more-alike-than-different/): While the day-to-day operations of an LTC pharmacy may be drastically different from retail pharmacies, auditors frequently treat them the same, especially when it comes to documentation requirements. 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
- [Making Prescription Annotations Audit-Ready](https://paasnational.com/making-prescription-annotations-audit-ready/): In a perfect world, all prescriptions received by your pharmacy would be 100% accurate with no need to follow up with the prescriber for clarification. Since we do not live in that utopian paradise, it is a common occurrence that prescriptions come over with invalid or non-specific quantities, incomplete or unclear directions, or other errors
- [Using SCC 13 Correctly: Protecting Claims in Disaster Situations](https://paasnational.com/using-scc-13-correctly-protecting-claims-in-disaster-situations/): Pharmacies serve a vital role in supporting their communities, especially when patients face disruptions during natural disasters. In such events, access to essential medication can be compromised. While helping patients through these challenging times, ensure that your pharmacy’s claims remain protected by confirming staff understand which override(s) to use and how to apply them correctly.
- [Time is Running Out! Is Your 2025 Training Complete?](https://paasnational.com/time-is-running-out-is-your-2025-training-complete/): As the year winds down, it is important to verify that all staff have completed their required training. Once the clock strikes midnight on December 31st, all 2025 training requirements must be completed. If the pharmacy has staff who have not completed their training by this deadline, the pharmacy will be considered non-compliant with CMS
- [USP 800 Compliance Program Updates: NIOSH 2024 List](https://paasnational.com/usp-800-compliance-program-updates-niosh-2024-list/): USP 800 outlines the standards for healthcare providers that handle hazardous drugs, as defined by the National Institute for Occupational Safety and Health (NIOSH). Pharmacies that handle hazardous drugs (including carbamazepine, clonazepam, colchicine, and cyclosporine ...
- [Off-Label: Why Drugs Like Ivermectin Spark Debate](https://paasnational.com/off-label-why-drugs-like-ivermectin-spark-debate/): Off-label use refers to the practice of prescribing a medication for a purpose, dosage, patient group, or form of administration that has not been approved by the FDA.
- [Avoiding Recoupments: Why Accurate 11-Digit NDC Billing Matters](https://paasnational.com/avoiding-recoupments-why-accurate-11-digit-ndc-billing-matters/): Matching all 11-digits of the NDC billed to the NDC dispensed is one critical step in ensuring the pharmacy has adequate records to support the appropriateness of every claim billed.
- [Are You Familiar with Qualified Medicare Beneficiary (QMB) Billing Obligations?](https://paasnational.com/are-you-familiar-with-qualified-medicare-beneficiary-qmb-billing-obligations/): Qualified Medicare Beneficiary (QMB) is a program for patients that have Medicare Parts A and B coverage and qualify for additional coverage through Medicaid.
- [Electronic Prescriptions: Upcoming Changes to Quantity and Unit of Measure](https://paasnational.com/electronic-prescriptions-upcoming-changes-to-quantity-and-unit-of-measure/): The National Council for Prescription Drug Programs (NCPDP) is a not-for-profit organization that develops and promotes standards for the exchange of information within the pharmacy services space. This organization develops the e-prescribing SCRIPT standard as well as the pharmacy billed D.0 standard (among other things).
- [The Fallout of Inflated Usual & Customary Pricing](https://paasnational.com/the-fallout-of-inflated-usual-customary-pricing/): According to a March 27, 2025 U.S. Department of Justice press release, Walgreens has agreed to pay over $2.8 million to settle allegations of overbilling Medicaid Programs in Massachusetts and Georgia. Allegedly, Walgreens was submitting a higher usual and customary (U&C) price on certain generic drugs billed to these Medicaid programs which caused Medicaid to pay more than they should have.
- [Incorrect Billing on Nayzilam® and Valtoco® Can Cost You](https://paasnational.com/incorrect-billing-on-nayzilam-and-valtoco-can-cost-you/): Nayzilam® and Valtoco® are indicated for the short-term treatment of seizure clusters that are distinct from a patient's usual seizure pattern in patients with epilepsy.
- [Update: Isentress® and Dificid® Added to Dispense in Original Container Chart](https://paasnational.com/update-isentress-and-dificid-added-to-dispense-in-original-container-chart/): OptumRx continues to focus audits on prescriptions that must be dispensed in their original container per the manufacturer’s [FDA approved] labeling and package insert.
- [Fraudulent Prior Authorization Submissions Costs Pharmacy Over $1 Million](https://paasnational.com/fraudulent-prior-authorization-submissions-costs-pharmacy-over-1-million/): A Florida-based pharmacy plead guilty to healthcare fraud and agreed to pay over $1 million to resolve False Claims Act violations stemming from falsified prior authorizations. The pharmacy dispensed Evzio® (injectable naloxone product for emergency treatment of opioid overdose—discontinued in October 2020) which frequently required prior authorizations due to its high cost. Instead of sending
- [Manufacturer Coupons: Why It’s Important to Read the Fine Print](https://paasnational.com/manufacturer-coupons-why-its-important-to-read-the-fine-print/): While PAAS National® sees a vast array of PBM audits daily, did you know that claims billed to a manufacturer coupon can also be audited by the coupon administrator? Each manufacturer coupon... Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive
- [What’s New with Prescription Validation Requests in 2025?](https://paasnational.com/whats-new-with-prescription-validation-requests-in-2025/): In the PAAS National® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024.
- [Preventing Misfill Recoupments Through Documentation](https://paasnational.com/preventing-misfill-recoupments-through-documentation/): PAAS National recommends attention to detail when it comes to typing directions for patient labels. Pharmacies are often very familiar with prescribers and what they likely intended to include on the prescription, but didn’t. This can range from a specifying a quantity to providing detailed patient instructions. Unfortunately,... Become an audit assistance member today to continue
- [New PAAS Tool! Flowchart for Multi-Payor Claims with Conflicting Coverage](https://paasnational.com/new-paas-tool-flowchart-for-multi-payor-claims-with-conflicting-coverage/): In last month’s Newsline article, “A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims, PAAS National provided insight into the revised billing process for multi-payor claims where one payor prefers the brand and the other payor prefers generic. Due to the complexity of this billing process, a
- [Reduce Vaccine Audit Risk Through Accurate Quantity Billed](https://paasnational.com/reduce-vaccine-audit-risk-through-accurate-quantity-billed/): To enhance profitability, pharmacy owners and operators have frequently incorporated immunization services into their offerings. While vaccines tend to carry a lower audit risk, the higher the cost of the vaccine, the more likely it is to be audited. The audit risk also increases when core billing elements of the vaccine claim are adjudicated incorrectly.
- [From Headache to Hassle Free: Best Practices in Migraine Medication Billing](https://paasnational.com/from-headache-to-hassle-free-best-practices-in-migraine-medication-billing/): Migraine medications continue to be targeted for audit by all PBMs. With new products on the market, rising costs, and frequency of refills, PBMs are looking for billing errors to claw back payments on audit. OptumRx’s latest tactic... Become an audit assistance member today to continue reading this article. As a member, you’ll have access
- [Bowel Prep Kit Billing Under CMS Review: PBMs in Focus](https://paasnational.com/bowel-prep-kit-billing-under-cms-review-pbms-in-focus/): Recent CMS audits have brought renewed attention to how PBMs oversee pharmacy billing for bowel preparation kits. Common issues listed below are leading to potential compliance violations and recoupments. Pharmacies and PBMs alike are urged to review current practices to ensure alignment with federal guidelines and reduce audit risks. PAAS National® is seeing the following
- [Billing and Filling: Glucagon Emergency Products](https://paasnational.com/billing-and-filling-glucagon-emergency-products/): Glucagon emergency products are typically low audit risk - when billed correctly. Billing the wrong unit of measure, like “EA” instead of “mL”, is an easy target for auditors to flag. Below is a table to aid in billing the correct unit of measure. Become an audit assistance member today to continue reading this article.
- [Why Adhering to Your Return to Stock Policy Is So Important](https://paasnational.com/why-adhering-to-your-return-to-stock-policy-is-so-important/): Pharmacies often struggle with patients not picking up prescriptions on a timely basis. The lag time could be caused by several reasons - cost concerns, transportation issues, mental health factors, or miscommunication are just a few of the possibilities. While pharmacies are sympathetic to patient situations, it is prudent to be aware of the consequences
- [Medicare Prescription Drug Coverage and Your Rights (CMS-10147)](https://paasnational.com/medicare-prescription-drug-coverage-and-your-rights-cms-10147/): When a pharmacy receives an NCPDP Reject Code 569 on a Medicare Part D claim, the pharmacy “must” provide the patient with the CMS-10147 form, also known as the Medicare Prescription Drug Coverage and Your Rights notice. The notice instructs enrollees about their right to contact their
- [Proof of Patient Consent for a Refill Request: What You Need to Know](https://paasnational.com/proof-of-patient-consent-for-a-refill-request-what-you-need-to-know/): If you are a DMEPOS supplier billing Medicare Part B claims, then you should be familiar with the proof of refill request requirement. All DMEPOS items and supplies billed to Medicare Part B that are delivered or mailed require proof of refill request and an affirmative response to occur and be documented prior to shipment.
- [“A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims](https://paasnational.com/a-for-abandoned-the-short-life-of-daw-code-a-and-what-it-means-for-multi-payor-claims/): Just 11 short months ago, PAAS National® released the NEW Dispense As Written (DAW) Code Revealed Newsline article about DAW code value “A” (408-D8). DAW A was designed to be utilized on multi-payor claims when one payor required a multi-source brand (or reference biologic with an approved interchangeable biosimilar in the marketplace) and the other
- [When Precision Fails: The Hidden Issues in Insulin Pen Dosing Calculations](https://paasnational.com/when-precision-fails-the-hidden-issues-in-insulin-pen-dosing-calculations/): Undoubtedly, a calculator can be found near every data entry and verification station throughout the prescription workflow line. This is, in part, due to PBM requirements that prescriptions have a mathematically calculable set of instructions. Consequently, pharmacies should strive to bill every claim with an appropriate quantity and days’ supply to prevent claim recoupment issues
- [LTC Essentials: A Guide to Residence Codes, Pharmacy Service Types, and Submission Clarification Codes](https://paasnational.com/ltc-essentials-a-guide-to-residence-codes-pharmacy-service-types-and-submission-clarification-codes/): With more pharmacies exploring the world of long-term care and LTC Pharmacy at Home dispensing increasing daily, PAAS National® has also been seeing audits on these claims. One area PBMs have been targeting surrounds... Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles
- [Filling Prescriptions with Two NDCs – What You Need to Consider](https://paasnational.com/filling-prescriptions-with-two-ndcs-what-you-need-to-consider/): We’ve all been in the sticky situation of having a few straggling pills left associated with one NDC that would be ideal to get off the shelf and free up some space. Maybe this NDC used to be the preferred product and now it has changed, or the manufacturer was bought out by another company.
- [NCPDP Package Size Updates: Gonal-f® RFF Redi-ject® and Teriparatide (Alvogen)](https://paasnational.com/ncpdp-package-size-updates-gonal-f-rff-redi-ject-and-teriparatide-alvogen/): Similar to the recent package size changes for Forteo®, NCPDP reports that the FDA has requested product labeling changes on four additional products which will be revised in compendia this summer. The FDA is not requiring manufacturers to obtain new NDCs and there are no clinical changes to the products. Products with coming package size
- [OIG Semiannual Report to Congress Shows 11:1 Return On Investment](https://paasnational.com/oig-semiannual-report-to-congress-shows-111-return-on-investment/): The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Semiannual Report to Congress summarizing program integrity efforts from October 2024 through March 2025 which showed a return of $11 for every $1 spent. The OIG is the lead federal agency combating healthcare fraud, waste, and abuse in federal
- [AstraZeneca Letters re: Farxiga® Data Discrepancies](https://paasnational.com/astrazeneca-letters-re-farxiga-data-discrepancies/): Numerous pharmacies have received letters from AstraZeneca, the manufacturer of Farxiga® 5 and 10 mg, regarding “discrepancies” identified in a reconciliation of purchase and dispensing data from 2024. 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
- [COVID-19 Vaccine Update: Shared Clinical Decision-Making](https://paasnational.com/covid-19-vaccine-update-shared-clinical-decision-making/): The CDC recently revised recommendations for COVID-19 vaccination by (i) removing the recommendation for pregnant women to receive the vaccine and (ii) that individuals ages 6 months to 17 years may receive the vaccine using a shared clinical decision-making (SCDM) approach. The SCDM recommendations are meant to be flexible and informed by the characteristics, values,
- [GLP-1 Prescriptions Remain in the Crosshairs of Auditors](https://paasnational.com/glp-1-prescriptions-remain-in-the-crosshairs-of-auditors/): GLP-1 medications continue to come under scrutiny from PBM auditors for several reasons. High cost, off-label use, rising utilization, and billing irregularities make these easy audit targets. Pharmacies must remain diligent to ensure accuracy and appropriateness when dispensing these medications to avoid recoupments. The latest in audit recoupments have come from... Become an audit assistance
- [Largest Health Care Fraud Takedown in History](https://paasnational.com/largest-health-care-fraud-takedown-in-history/): We are living in unprecedented times as the Justice Department announced the outcome of their 2025 National Health Care Fraud Takedown, marking one of the largest enforcement actions of its kind. Criminal charges were filed against 324 individuals, from various health care professions, for their alleged participation in a range of fraud schemes. The total
- [Flu Shot Season Is Upon Us – Are You Prepared for an Audit?](https://paasnational.com/flu-shot-season-is-upon-us-are-you-prepared-for-an-audit/): As the flu shot season starts, PAAS National® wants to make sure you are ready to properly document these routine vaccines in case of an audit. Now is the time to check that you have all required documentation in place for this year’s flu shot season. What is needed upon an audit: Become an audit
- [Do You Have Adequate Proof of Patient Copay Collection?](https://paasnational.com/do-you-have-adequate-proof-of-patient-copay-collection/): PBMs require pharmacies to not only collect patient copays, but also have documentation to prove it. It is common for PBMs to request proof of copay collection when performing audits. Copays are used by the insurers to help patients understand medication costs and to encourage less costly alternatives. Pharmacies that alter or waive copays set
- [Stay in the Know: Caremark Aberrant Practices and Trends](https://paasnational.com/stay-in-the-know-caremark-aberrant-practices-and-trends/): PAAS National analysts continue to see pharmacies fall victim to Caremark’s Aberrant Practices and Trends enforcement. 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
- [From Problem to Progress: Best Practices for Corrective Action Plans (CAP)](https://paasnational.com/from-problem-to-progress-best-practices-for-corrective-action-plans-cap/): A Corrective Action Plan (CAP) is a document your pharmacy may develop in response to issues that arise (e.g., negative audit findings), helping to identify root causes, and how your pharmacy will prevent the same discrepancies from happening in the future. You may choose to develop your own informal CAP to help train or retrain
- [Is the Medicare Prescription Payment Plan Likely to Benefit Notice (CMS Form 10882) Expired?](https://paasnational.com/is-the-medicare-prescription-payment-plan-likely-to-benefit-notice-cms-form-10882-expired/): CMS Form 10882 is a Medicare notice that Plan Sponsors (via CMS directive) require pharmacies to provide to patients if a prescription copay for a Medicare Part D claim exceeds $600. This distribution requirement started January 1, 2025, and is prompted by an Approval Message Code 056. The expiration date on the current version of
- [DUR & SCC Code Documentation: Your Defense Against Costly Recoupments](https://paasnational.com/dur-scc-code-documentation-your-defense-against-costly-recoupments/): PAAS National frequently emphasizes the importance of accurate documentation for Submission Clarification Codes (SCCs) and Drug Utilization Review (DUR) codes. This is not just best practice, it is essential to protect your claims. Audit chargebacks due to improper or unsupported override codes are notoriously difficult to appeal; therefore, it’s critical to proceed with caution. Lack
- [Compliance Check: Is Your Authority to Vaccinate Still Valid?](https://paasnational.com/compliance-check-is-your-authority-to-vaccinate-still-valid/): Vaccine season is upon us! Pharmacies who offer immunization services are likely seeing an influx in requests for seasonal influenza, COVID-19, and other routine vaccines. However, it is important to take a step back and evaluate exactly which vaccines you are formally allowed to authorize and administer, especially after the meeting of the Advisory Committee
- [Avoid Early Refills on Titration Prescriptions for Audit Success](https://paasnational.com/avoid-early-refills-on-titration-prescriptions-for-audit-success/): Community pharmacies are always looking for ways to provide better care for patients. A primary focus continues to be on customer service - whether it be cost savings on prescriptions, convenience of delivery or med-sync programs. When a patient presents to the pharmacy with a new prescription, the focus is on education and adherence. Wouldn’t
- [OTC COVID-19 Tests Are Still on Auditor Radars](https://paasnational.com/otc-covid-19-tests-are-still-on-auditor-radars/): While the COVID-19 Public Health Emergency officially ended on May 11, 2023, the 12th Amendment of the Public Readiness and Emergency Preparedness Act (PREP) was extended until December 31, 2029. This allows pharmacies to continue dispensing OTC COVID-19 tests to patients without a prescription. Many state Medicaid and commercial insurance plans continue to cover this
- [New DUR Codes for Insulin Method of Administration](https://paasnational.com/new-dur-codes-for-insulin-method-of-administration/): If your pharmacy dispenses rapid-acting insulin, be ready to start closely evaluating the patient’s method of administration. Knowing whether a patient is using the rapid-acting insulin for direct injection (via syringe or pre-filled pen), with a disposable insulin pump, or in a qualifying DME pump will become critical to claim payment starting in October. Become
- [Real-World Examples of Fraud, Waste & Abuse and Audit Implications](https://paasnational.com/real-world-examples-of-fraud-waste-abuse-and-audit-implications/): It is no secret that margins are thin and pharmacies have been looking for additional revenue-generating opportunities. Some pharmacies have added immunization services, performed billable Medication Therapy Management, added Point of Care Testing, and/or found other non-PBM income sources to offset low (or negative) reimbursements from third-party payors. These services are patient-focused and can increase
- [When Can a Wrong Origin Code Lead to Denial or Recoupment?](https://paasnational.com/when-can-a-wrong-origin-code-lead-to-denial-or-recoupment/): Per NCPDP’s Telecommunication Version D and Above: Questions, Answers and Editorial Updates, “the Prescription Origin Code (419-DJ) contains the value that represents the method in which the pharmacy originally received the prescription from the prescriber.” Any subsequent changes or modifications to the original prescription do not change the origin code even when clarifications of that
- [Easy Pickings: Why Transferred Prescriptions are Audit Bait](https://paasnational.com/easy-pickings-why-transferred-prescriptions-are-audit-bait/): Transferring prescriptions into your pharmacy is usually great for business; however, pharmacies must be aware of the additional audit risks with these prescriptions. PBM audit algorithms easily identify transfers due to the origin code of 5 being submitted during claim adjudication. Each state has requirements put in place by their pharmacy board that outline what
- [Billing Ozempic® 0.25 mg Weekly as a Maintenance Dose – What is the Big Deal?](https://paasnational.com/billing-ozempic-0-25-mg-weekly-as-a-maintenance-dose-what-is-the-big-deal/): PAAS National analysts field many questions on Ozempic® relating to off-label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing. Section 2.2 of the manufacturer package insert (available on DailyMed) lists the recommended dosage schedule based on clinical trials and includes the following titration schedule:
- [Billing Considerations That Will Save You Later](https://paasnational.com/billing-considerations-that-will-save-you-later/): Filing and billing claims involves keeping track of what can feel like an endless number of details. The fast-paced environment of the pharmacy doesn’t always allow for keeping tedious details at the forefront of your mind. Below you’ll find a guide detailing common scenarios that should be considered while filling prescriptions to reduce your audit
- [Illegible Signature? Auditors Are Taking Note!](https://paasnational.com/illegible-signature-auditors-are-taking-note/): A recent audit trend shows that some major PBMs are challenging the perceived legitimacy of patient signatures. In particular... 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
- [Empowering Pharmacy Teams to Decrease Audit Risk](https://paasnational.com/empowering-pharmacy-teams-to-decrease-audit-risk/): Sir Francis Bacon is often credited with stating “scientia potentia est” in his published work, Meditationes Sacrae from 1597. This Latin phrase roughly translates to “knowledge is power” and while this turn of phrase is centuries old, it holds true today. The pharmacy industry is an ever-changing world and staying up to date on audit
- [What Is a Targeted Probe and Educate Audit?](https://paasnational.com/what-is-a-targeted-probe-and-educate-audit/): CMS rolled out the Targeted Probe and Educate (TPE) program back in 2017. The goal of the TPE program is to help providers reduce the number of DMEPOS claim denials by using data analysis and providing one-on-one educational sessions to avoid common mistakes. DME Medicare Administrative Contractors (MACs) analyze data to identify providers who have
- [The $40 Incentive Fee You Might Be Missing!](https://paasnational.com/the-40-incentive-fee-you-might-be-missing/): Since 2021, a program created by CMS has allowed eligible pharmacies to receive additional reimbursement for administering the COVID-19 vaccine to certain Medicare homebound patients. 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
- [USP 800: What Community Pharmacies Need to Know](https://paasnational.com/usp-800-what-community-pharmacies-need-to-know/): Most community pharmacies don’t compound with hazardous drugs, but that doesn’t mean you’re off the hook when it comes to USP 800 compliance. This standard, USP General Chapter Hazardous Drugs: Handling in Healthcare Settings, applies to anyone who receives, stores, or dispenses hazardous drugs (HDs). And yes, that includes community pharmacies. What Makes a
- [Where Can I Find PBM Provider Manuals?](https://paasnational.com/where-can-i-find-pbm-provider-manuals/): Each PBM has their own unique set of “rules” for network pharmacies to follow, and they publish these rules in their Provider Manual. Pharmacies should be aware these Provider Manuals are an extension of the Provider Agreement and contractually obligate pharmacies to adhere to these requirements. To make matters worse, PBMs update these manuals at
- [Be Aware of Federal Crackdown on Health Care Fraud](https://paasnational.com/be-aware-of-federal-crackdown-on-health-care-fraud/): Across the country, health care fraud affects all areas of the healthcare system, but how does it affect your pharmacy? Bad actors in pharmacy give validation to PBM audit practices, adding to the audit burden. PBMs leverage these audits as a method to keep the “bad actors” out of the health care field and save
- [Caremark LTC Override Code Audits](https://paasnational.com/caremark-ltc-override-code-audits/): Caremark frequently issues desk audits, labeled as LTC Override Code Audits, to validate certain override codes that allow LTC pharmacies to process claims without having to call the helpdesk (generally due to early refill rejections). Submission Clarification Codes (SCC) may be input by pharmacies into NCPDP field 420-DK to identify unique dispensing situations such as
- [Final Audit Results…Or Are They?](https://paasnational.com/final-audit-resultsor-are-they/): Receiving audit results that have discrepancies with financial recoupment is never something a pharmacy wants to endure, but PAAS National® is here to help! It is important to know that audit results may not provide all potential avenues for appeal. Even if your initial appeal is denied, there may still be an opportunity to overturn
- [CERT Improper Payment Rates: DMEPOS](https://paasnational.com/cert-improper-payment-rates-dmepos/): Each fiscal year, the Department of Health and Human Services (HHS) publishes improper payment rates for Medicare FFS Part A, Part B, and DMEPOS claims submitted between July 1 and June 30. These error rates are determined through Comprehensive Error Rate Testing (CERT) audits of a stratified, randomized sample of claims across various provider types
- [FreeStyle Libre 2 and 3 Sensors to be Discontinued](https://paasnational.com/freestyle-libre-2-and-3-sensors-to-be-discontinued/): Abbott has announced that the FreeStyle Libre 2 and FreeStyle Libre 3 sensors will no longer be available after September 30, 2025. Patients that are currently filling prescriptions for these products will need to obtain new prescriptions for the FreeStyle Libre 2 Plus or FreeStyle Libre 3 Plus sensors. FreeStyle Libre 2 Plus sensors can
- [Tips on Days’ Supply Calculations for Foam Products](https://paasnational.com/tips-on-days-supply-calculations-for-foam-products/): PAAS National® receives many questions about topical prescriptions, including more complicated products like foam dosage form medications. These products often come in pressurized aluminum cans without a clear way of measuring the product when dispensing. In addition to this issue, prescribers often send prescriptions to the pharmacy with a vague set of instructions. PBMs are
- [Would Your EPIPEN® Claims Pass an Audit?](https://paasnational.com/would-your-epipen-claims-pass-an-audit/): PAAS National continues to see a large number of EPIPEN® prescriptions flagged for audit, as well as targeted on OptumRx prescription validation requests. The PBMs often target EPIPEN® products due to their higher cost and confusion around proper billing practices and product substitution. Adhering to the guidance below can help avoid billing issues and reduce
- [Days’ Supply Mistakes: A Fast Track to Recoupment](https://paasnational.com/days-supply-mistakes-a-fast-track-to-recoupment/): Calculating the days’ supply on a claim is something every pharmacy does throughout the workday. With a multitude of claims, clerical errors are bound to happen. What are the audit consequences when a days’ supply is billed incorrectly? Become an audit assistance member today to continue reading this article. As a member, you’ll have access
- [Are You Billing Divigel® Correctly?](https://paasnational.com/are-you-billing-divigel-correctly/): Billing packaged products according to their proper size and unit of measure is crucial for pharmacies, as this common pitfall could result in hefty recoupments from PBMs. When it comes to billing insurance, a medication like Divigel® (estradiol) transdermal gel packets can be confusing for pharmacies, as different strengths use different billing units. Some are
- [When Medicaid is the Secondary Payor](https://paasnational.com/when-medicaid-is-the-secondary-payor/): Billing insurance isn’t always simple, whether it’s formulary issues, step therapy or plan limitations, it’s common for a pharmacy to receive a rejection when trying to bill a patient’s insurance. For patients with Medicaid as secondary coverage, can you simply send the rejected claim to Medicaid? Caution should be exercised. Become an audit assistance
- [Dexcom G6/G7 Sensors: Retail vs DME](https://paasnational.com/dexcom-g6-g7-sensors-retail-vs-dme/): PAAS National® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites
- [Why Are There So Many Audits? ](https://paasnational.com/why-are-there-so-many-audits/): Many pharmacies that PAAS National® assists with audits have similar sentiments, “Why us?” or “We just had an audit with [insert PBM here]”. It can feel like it is a never-ending cycle, with shifting standards depending on which PBM is conducting the audit. At PAAS, we understand these concerns — and we’re here to help.
- [DEA Alert: Electronic Prescription Fraud on the Rise](https://paasnational.com/dea-alert-electronic-prescription-fraud-on-the-rise/): As technology continues to reshape modern medicine, medical providers have embraced electronic prescribing to improve patient care. Unfortunately, as the healthcare landscape evolves, so do the tactics of bad actors seeking to exploit it. Bad actors can use stolen login credentials from prescribers to gain access to electronic health record systems and initiate thousands of
- [PBMs Are Criticizing Clinical Notes!](https://paasnational.com/pbms-are-criticizing-clinical-notes/): Calling a prescriber’s office due to a prescription with missing elements, or needing clarification, is an inescapable task. If you are failing to document that phone call with a valid clinical note, PBMs may flag the claim upon audit and try to recoup. We have seen OptumRx, Humana, Navitus, and ESI/Prime results citing pharmacy clinical
- [Delivering to a Clinic? Avoid Audit Risks!](https://paasnational.com/delivering-to-a-clinic-avoid-audit-risks/): Traditional dispensing for independent pharmacies continues to transform. Beyond dispensing prescriptions at the pharmacy counter, some pharmacies are providing patient-specific prescriptions directly to clinics for administration. Pharmacies must be aware and protect themselves from the heightened audit risks. While PAAS National® has written countless Newsline articles on signature, delivery, and mailing requirements to help our
- [Unannounced CMS Site Visits](https://paasnational.com/unannounced-cms-site-visits/): PAAS National® has recently seen an uptick in the number of unannounced CMS site visits related to Medicare enrollment or revalidation. These visits are currently being conducted by Novitas Solutions, the contracted National Provider Enrollment East (NPEast) contractor and Palmetto GBA® for the NPWest. Site visits are performed to verify the business location and ensure
- [Combo Shop Pharmacy Inventory Considerations](https://paasnational.com/combo-shop-pharmacy-inventory-considerations/): Independent pharmacies are diving into the long-term care world to improve care for their patients and maximize revenue. Pharmacies can run both retail and combo-shop LTC pharmacies under one roof; typically with the same computer system. However, even though the pharmacies have a single location, the processing of claims and sharing of drug inventory can
- [Audit and Appeal Due Dates: Stay Ahead of the Clock with These Essential Tips](https://paasnational.com/audit-and-appeal-due-dates-stay-ahead-of-the-clock-with-these-essential-tips/): Pharmacy practice often revolves around meeting tight deadlines. Prioritizing can become challenging when you’re focused on providing prompt service to waiting patients or rushing to meet inventory ordering deadlines, all while managing your daily tasks. It’s tempting to push aside a PBM audit request, or its results, to tackle more immediate responsibilities. Unfortunately, neglecting audit
- [Can Claims Under Audit Be Reversed?](https://paasnational.com/can-claims-under-audit-be-reversed/): You’re preparing for an upcoming desk audit, and while pulling the hard copies for a PAAS National analyst to review, you notice a billing error. It’s a simple fix, like an incorrect days’ supply, so you try to reprocess the claim. However, now you’re hit with an unexpected rejection ... Become an audit assistance member today
- [Proof of Patient Counseling Required!](https://paasnational.com/proof-of-patient-counseling-required/): Pharmacies are familiar with submitting copies of prescriptions, signature logs and proof of copay collection upon an audit request, but do you have documented proof of the offer to counsel? While the patient can accept or refuse counseling, it must be documented for Medicaid patients. PAAS National analysts often see pharmacies with these requests during Medicaid
- [Eye Drop Guidance Updates: Prime Therapeutics](https://paasnational.com/eye-drop-guidance-updates-prime-therapeutics/): Prime Therapeutics acquired Magellan Rx in 2022 and released the first “integrated” Provider Manual for network pharmacies in January 2024. An important change in the revised Provider Manual is the guidance for billing eye drop medications, which carries billing and audit implications.
- [Understanding the DEA Exempted Product List](https://paasnational.com/understanding-the-dea-exempted-product-list/): When working directly with prescription medications in the pharmacy, it is generally easy to tell which drugs are controlled substances and which aren’t.
- [Preparing for Onsite Audit Success](https://paasnational.com/preparing-for-onsite-audit-success/): Since the expiration of the COVID-19 Public Health Emergency in May 2023, PAAS National® has seen a significant increase in on-site audit notices from PBMs across the board.
- [OptumRx® Continues to Pocket More Money from Days’ Supply Issues](https://paasnational.com/optumrx-continues-to-pocket-more-money-from-days-supply-issues/): OptumRx® continues to maximize chargebacks on pharmacies due to days’ supply errors. It’s important to take the extra time to confirm billing elements are accurate prior to adjudicating – this could save you on the back end of an audit.
- [Is Your Pharmacy Prepared for a Cyberattack?](https://paasnational.com/is-your-pharmacy-prepared-for-a-cyberattack/): In this episode of The Bottom Line Pharmacy Podcast, Scotty Sykes, CPA, CFP and Austin Murray sit down with Trenton Thiede, President of PAAS National, to unpack the rising cybersecurity threats facing independent pharmacies and what owners must do to stay compliant and protected.
- [Keeping Your Suboxone Claims Safe from Recoupment ](https://paasnational.com/keeping-your-suboxone-claims-safe-from-recoupment/): As of December 29, 2022, the DEA no longer requires prescribers to include a DATA 2000 Waiver ID (commonly called an “XDEA number”) on buprenorphine prescriptions used to treat patients with opioid use disorder via the Consolidated Appropriations Act of 2023. With additional prescribers now able to issue prescriptions, and opioid dependence still plaguing America,
- [Medicare Billing for Insulin Pump Therapy](https://paasnational.com/medicare-billing-for-insulin-pump-therapy/): Pharmacies billing insulin vials for eligible Medicare patients must pay extra attention to ensure proper coverage. Since the frequency of dispensing insulin vials has greatly decreased due to the introduction of insulin pens, it is very important pharmacies take a pause and investigate how the patient is utilizing the insulin vials. Medicare covers insulin vials
- [Oral Inhalers – What You Need to Know About Institutional Pack Sizes](https://paasnational.com/oral-inhalers-what-you-need-to-know-about-institutional-pack-sizes/): Oral inhaler prescriptions are frequently targeted for audit by PBMs because of their cost, frequent billing errors (e.g., incorrect days’ supply), or prescribing errors (e.g., non-mathematically calculable directions or incorrect written quantity). Vague written quantities can cause recoupments when multiple package sizes exist, including institutional package sizes. Become an audit assistance member today to continue
- [FDA Approves First Rapid-Acting Insulin Biosimilar: MerilogTM (insulin aspart-szjj)](https://paasnational.com/fda-approves-first-rapid-acting-insulin-biosimilar-merilogtm-insulin-aspart-szjj/): On February 14, 2025, the FDA approved the first rapid-acting insulin biosimilar, MerilogTM (insulin aspart-szjj) manufactured by Sanofi Aventis. MerilogTM is expected to reach the U.S. market in July 2025 and will require prescriber approval before pharmacies can substitute for other insulin aspart products such as Fiasp® or NovoLog®. MerilogTM is the third insulin biosimilar
- [Mailing Prescriptions? How to Ensure Audit Success](https://paasnational.com/mailing-prescriptions-how-to-ensure-audit-success/): While some pharmacies make mailing prescriptions a regular practice, others may only do so on a case-by-case basis. PBMs require signature logs to prove that a patient received their medication in a timely manner, but how is proof obtained when the patient is not standing in front of you at the pharmacy counter? Become an
- [Audit Considerations for Med Sync Programs](https://paasnational.com/audit-considerations-for-med-sync-programs/): Medication synchronization (med sync) programs are common across pharmacies and yield many benefits. Patients can request it to manage medication better and reduce the number of trips needed to the pharmacy. Patient adherence increases and pharmacies can keep tighter control over inventory while having more efficient workflow. NCPA promotes the improved adherence and quality of
- [Respiratory Syncytial Virus (RSV) – What You Need to Know](https://paasnational.com/respiratory-syncytial-virus-rsv-what-you-need-to-know/): There are currently three FDA-approved Respiratory Syncytial Virus (RSV) vaccines available for individuals at risk of severe illness from a respiratory virus. Please review the chart for helpful billing tips and the additional information below as to which RSV vaccine is appropriate to give to an eligible individual. Become an audit assistance member today to
- [Medicare Part A vs Part D Billing Risks – How to Protect Your Claims](https://paasnational.com/medicare-part-a-vs-part-d-billing-risks-how-to-protect-your-claims/): Pharmacies continue to receive PBM audit notices for claim recoupments where the [allegedly] improper Medicare coverage was billed. Medicare Part A helps cover hospital, skilled nursing facility (SNF), and hospice care stays. Medicare coverage status is typically linked to the patient’s admission and discharge dates from a Part A stay. When a patient is covered
- [Diabetic Test Strip Authorized Distributors – LifeScan Audits Continue!](https://paasnational.com/diabetic-test-strip-authorized-distributors-lifescan-audits-continue/): Independent pharmacies continue to receive letters regarding the purchase of OneTouch® test strips, manufactured by LifeScan. We have seen two variations of these letters – one “warning” letter from LifeScan directly and a second letter demanding repayment for invoice shortages from a law firm acting on LifeScan’s behalf. Both letters contend that pharmacies submitted more
- [Changing Pharmacy Management Software? Don’t Neglect Record Retention!](https://paasnational.com/changing-pharmacy-management-software-dont-neglect-record-retention/): When updating or changing pharmacy management software systems, pharmacies may be presented with different options to archive the files from the software they will no longer be using. While it may not seem worth the extra cost now, ensuring that you are able to retrieve appropriate data for old claims is crucial to avoiding costly
- [Verify Day’s Supply on CeQur Simplicity Meal-Time Insulin Patch](https://paasnational.com/verify-days-supply-on-cequr-simplicity-meal-time-insulin-patch/): CeQur SimplicityTM is a meal-time insulin patch approved for use in adult patients (over the age of 21) with Type 2 Diabetes and can replace up to 12 meal-time insulin doses. The patch delivers rapid-acting insulin in 2-unit doses through a flexible cannula by depressing two buttons, one on each side of the patch. This
- [Updated Form Expiration 12/31/2027 – Medicare Drug Coverage and Your Rights Notice](https://paasnational.com/updated-form-expiration-12-31-2027-medicare-drug-coverage-and-your-rights-notice/): The CMS-10147 Form, also known as the Medicare Drug Coverage and Your Rights Notice, must be distributed to Medicare Part D beneficiaries when a prescription is not covered at the point-of-sale. This notice informs beneficiaries about their right to contact their Part D plan to request a coverage determination, including an exception. The distribution of the
- [Forteo® Package Size Update – Compendia Adjustment Expected April 1, 2025](https://paasnational.com/forteo-package-size-update-compendia-adjustment-expected-april-1-2025/): As previously reported by PAAS National® in our December 2024 Newsline article, the FDA revised the product labeling for Forteo® (teriparatide injection) and its generics to accurately reflect the amount of drug delivered to the patient and not the overfill existing in the pen injector delivery device (from a 600 mcg/2.4 mL pen to a 560 mcg/2.24 mL
- [Understanding Spravato® Strict Delivery Requirements](https://paasnational.com/understanding-spravato-strict-delivery-requirements/): Spravato® (esketamine) is a prescription nasal spray approved for treatment-resistant depression (TRD) and major depressive disorder (MDD) with suicidal thoughts. Due to its potential for misuse and serious side effects, Spravato® is subject to strict handling, administration, and monitoring requirements under the FDA’s Risk Evaluation and Mitigation Strategy (REMS). Become an audit assistance member today to continue
- [When the Margins Are Thin, Self-Audit for the Win](https://paasnational.com/when-the-margins-are-thin-self-audit-for-the-win/): It is no secret that margins on prescription medications have declined dramatically over the last few decades. Independent pharmacy owners are well aware of their less-than-favorable Pharmacy Benefit Manager (PBM) contracts, and their propensity to routinely audit. After working day in and day out to take care of the patients in your communities, auditors swoop
- [Template Forms Can Lead to Audit Problems](https://paasnational.com/template-forms-can-lead-to-audit-problems/): At a time when the workday seems to be growing ever more hectic, prescribers and pharmacies may find pre-printed prescription forms convenient; especially for medications which are frequently utilized by a prescriber for treatment. Unfortunately, many PBMs prohibit pre-printed prescription form use for various reasons. Become an audit assistance member today to continue reading this
- [Will Your Signature Logs Pass an Audit?](https://paasnational.com/will-your-signature-logs-pass-an-audit/): Since the beginning of the new year, PAAS National® has seen a 14% increase in audits from third-party payors (18% for onsite audits)! When collecting the requested documents for an audit, signature logs are commonplace. Invariably, the one patient who refuses to sign their name (or uses a smiley face instead) to confirm receipt of their
- [Audit Alert: Topical Nail Treatments](https://paasnational.com/audit-alert-topical-nail-treatments/): What do Jublia® (efinaconazole), ciclopirox (formerly Penlac®), and tavaborole (formerly Kerydin®) all have in common? Besides each being a topical solution for the treatment of onychomycosis (Jublia® and Kerydin® for toenails and Penlac® for fingernails and toenails), they also all require knowing the number of applications per bottle for calculating an accurate days’ supply. Unfortunately, manufacturers do not provide
- [Caremark Aberrant Practices and Trends – Enforcement Extends Beyond the Aberrant Product List](https://paasnational.com/caremark-aberrant-practices-and-trends-enforcement-extends-beyond-the-aberrant-product-list/): PAAS National® analysts have worked with numerous pharmacies who have received communications related to Caremark’s proprietary Aberrant Product List or other alleged Atypical Dispensing Patterns. These letters are driven by Caremark’s Provider Manual section 3.02.03 which was expanded in 2022 as discussed in the Newsline article, Caremark® Expands “Aberrant” Language & Restricts Bulk Purchases. These letters fall into two different categories:
- [The Next Big Wave: Anticipating a Surge in HIPAA Compliance Audits](https://paasnational.com/the-next-big-wave-anticipating-a-surge-in-hipaa-compliance-audits/): Desk audits, onsite audits, invoice audits…and HIPAA compliance audits?! Unfortunately every community pharmacy has some familiarity with third party payor audits, and PAAS National® audit analysts bring their expertise to guide members through the entire audit process, ensuring everything goes as smoothly as possible. But what about HIPAA compliance audits? With a potential surge in these
- [The NEW Inventory Transfer Log and Why it Could Save You Big!](https://paasnational.com/the-new-inventory-transfer-log-and-why-it-could-save-you-big/): PAAS National® analysts have walked many pharmacies through the ins and outs of invoice audits. During our consultations with members who have their results back, the question of “Why would my invoice not be accepted?” comes up regularly. The answer to this question is multifaceted and can take some investigative work to identify the root cause.
- [Continuous Glucose Monitor (CGM) Update – New Products Recently Released ](https://paasnational.com/continuous-glucose-monitor-cgm-update-new-products-recently-released/): There have been some updates to the continuous glucose monitor (CGM) world since our last Newsline article released March 2024. Abbott has released two new sensors, FreeStyle Libre 2 Plus Sensor and FreeStyle Libre 3 Plus Sensor, that can be used with the FreeStyle Libre 2 Reader and FreeStyle Libre 3 Reader, respectively. FreeStyle Libre
- [Using and Documenting Priming Units on Insulin Pens](https://paasnational.com/using-and-documenting-priming-units-on-insulin-pens/): In 1985, the first insulin pen was invented – it gave patients a flexible way of self-administration and autonomy from burdensome vials and syringes. Today there are a multitude of insulin products available as FlexPen®, FlexTouch®, KwikPen®, and Solostar® pens that offer convenience and discretion for patients with diabetes. The patient Instructions for Use, included
- [Electronic Prescription Fraud](https://paasnational.com/electronic-prescription-fraud/): Most community pharmacy employees know the “red flags” to spot a fraudulent written prescription such as it “looks too good”, has irregular quantities and instructions, different color ink or handwriting, and doesn’t follow the typical medical shorthand. Unfortunately, it is much harder to spot a fraudulent electronic prescription. The bad guys are now using sophisticated
- [Tennessee Pharmacist Conducts Multi-Million Dollar Health Care Fraud Scheme](https://paasnational.com/tennessee-pharmacist-conducts-multi-million-dollar-health-care-fraud-scheme/): In December 2024, a Tennessee pharmacist was arrested and charged with nine counts of Health Care Fraud and six counts of Aggravated Identity Theft for operating a health care fraud scheme that resulted in over $6 million worth of false claims being submitted to several insurers. A federal indictment returned in late December revealed that
- [Why PBMs Insist on Understanding Dispense Quantity Changes](https://paasnational.com/why-pbms-insist-on-understanding-dispense-quantity-changes/): When a pharmacy dispenses a quantity other than what was prescribed, it requires documentation. PBMs will want to know the rationale, whether the quantity was increased or decreased. There are plenty of valid reasons a pharmacy may need to change the quantity, including ... Become an audit assistance member today to continue reading this article.
- [Keeping the Diagnoses Straight for GLP-1 Products](https://paasnational.com/keeping-the-diagnoses-straight-for-glp-1-products/): The FDA recently announced that Zepbound® (tirzepatide) has been approved for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity. This is the first GLP-1 indicated for OSA. The popularity of GLP-1 products has not slowed down, but with the new diagnosis for Zepbound® it is a good time to
- [Top Ten Newsline Articles for 2024](https://paasnational.com/top-ten-newsline-articles-for-2024/): In today’s fast-paced world, it’s crucial to stay informed with the latest insights to avoid putting your pharmacy at risk. For all pharmacy staff, continuous education is key. Mailed to pharmacies with the January Newsline, this article reviews the top ten PAAS National® Newsline articles from 2024 that were the most read tips and trends
- [Unique Eyedrop Calculation Challenges](https://paasnational.com/unique-eyedrop-calculation-challenges/): Pharmacy social media platforms host passionate discussions on the correct way to bill days’ supply for eyedrops almost every week. Do you use 15 drops/mL, 20 drops/mL, or something else? As it turns out, the “right answer” depends on the PBM you are billing and if the eyedrop is a solution or a suspension. Sound
- [Best Practices for Out-of-Stock Medications](https://paasnational.com/best-practices-for-out-of-stock-medications/): PAAS National® analysts continue to see pharmacies struggle with invoice audits, which are most frequently performed by Caremark® and OptumRx®. 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
- [Oral-Only ESRD Drugs Removed from Medicare Part D Coverage in 2025](https://paasnational.com/oral-only-esrd-drugs-removed-from-medicare-part-d-coverage-in-2025/): Starting January 1, 2025, Medicare Part D no longer covers “oral-only” medications used for patients with end-stage renal disease (ESRD) undergoing dialysis treatment. This mainly impacts payment of phosphate binders such as PhosLo® (calcium acetate) and Renvela® (sevelamer carbonate), as well as Xphozah® (tenapor). Become an audit assistance member today to continue reading this article.
- [The HIPAA Hot Seat: What You Need to Know About the “2024 Privacy Rule” and Reproductive Health Care](https://paasnational.com/the-hipaa-hot-seat-what-you-need-to-know-about-the-2024-privacy-rule-and-reproductive-health-care/): The 2022 Dobbs v. Jackson Women’s Health Organization ruling, which overturned Roe V. Wade, prompted modifications to the Privacy Rule (45 CFR Parts 160 and 164). The Biden-Harris administration, partially through President Biden’s Executive Order (EO) 14076, aimed to better protect information related to reproductive health care, to bolster patient-provider confidentiality, and promote trust between
- [2024-2025 Self-Audit Series #12: Electronic Prescriptions](https://paasnational.com/2024-2025-self-audit-series-12-electronic-prescriptions/): This month’s article will wrap up the 2024-2025 Self-Audit Series. Our focus for this article is electronic prescriptions and their potential audit risks. Electronic prescriptions have solved some problems (e.g., indecipherable handwriting), but have also created new problems. By focusing on the following tips when reviewing your electronic prescriptions, you can help prevent significant recoupments.
- [Caremark Bulk Purchase Notification](https://paasnational.com/caremark-bulk-purchase-notification-2/): Did you make any “bulk purchases” of inventory in December 2024? If so, then you must act now to protect against a Caremark invoice audit that could happen in 2026! 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
- [PREP Act Extended Through 2029!](https://paasnational.com/prep-act-extended-through-2029/): Good news! The Public Readiness and Emergency Act (PREP Act) did not expire at the end of this year, according to a declaration published on December 11, 2024, by the U.S. Health and Human Services (HHS). The declaration has extended the authority for pharmacists, pharmacy interns and pharmacy technicians to administer vaccines and test patients
- [Are You Willing to Risk Recoupment for Missing DUR and SCC Documentation?](https://paasnational.com/are-you-willing-to-risk-recoupment-for-missing-dur-and-scc-documentation/): Pharmacies often work in a fast-paced environment with an increasing workload as we see stores closing, more transfer-ins, and higher patient demand. This results in an increased urgency to perform data entry faster, which can lead to the use of override codes to get the claim adjudicated quickly. PAAS National® is here to remind pharmacies
- [Vaginal Creams: Why 30 Days’ Supply Is Probably Not Appropriate](https://paasnational.com/vaginal-creams-why-30-days-supply-is-probably-not-appropriate/): Topical medications like creams and ointments are always a target for PBMs to audit, but lurking in those topicals is a bullseye that PBMs are always aiming for - vaginal creams. Estrace® and Premarin® are easy targets due to the variety of discrepancies that could be found when auditing. The most common error PAAS National®
- [PBM Prescription Validation Requests – What Are They Looking At Now?](https://paasnational.com/pbm-prescription-validation-requests-what-are-they-looking-at-now/): The July 2024 PAAS National® Newsline article, What’s New with Prescription Validation Requests in 2024? compared the top five drugs targeted in the first six months of 2024. The chart below shows the top drugs picked for claim reviews in the second half of 2024, and a recap of the first half of 2024. Become
- [2025 PAAS Fraud, Waste & Abuse and HIPAA Compliance Program Updates](https://paasnational.com/2025-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
- [Billing Ozempic® 0.25 mg Weekly as Maintenance – What PBMs Say](https://paasnational.com/billing-ozempic-0-25-mg-weekly-as-maintenance-what-pbms-say/): PAAS National® continues to see GLP-1 medications as a high audit target. Recall the FDA-approved initial dosing for Ozempic® is 0.25 mg injected subcutaneously once weekly for four weeks, followed by 0.5 mg once weekly (see section 2.2 of product labeling). However, pharmacies often see prescribers write for Ozempic® 0.25 mg weekly dose as maintenance.
- [Compound Supplier Medisca Pays $21.75 Million Over Inflated AWPs](https://paasnational.com/compound-supplier-medisca-pays-21-75-million-over-inflated-awps/): The Department of Justice recently announced that Medisca Inc. will pay $21.75 million to settle allegations of fraud involving inflated Average Wholesale Prices (AWPs) for two ingredients used in compound prescriptions - resveratrol and mometasone furoate. The government alleges that the scheme caused pharmacies to submit false claims to federal healthcare programs, including TRICARE and
- [Optimizing Prescriber Statements: Best Practices and Tips](https://paasnational.com/optimizing-prescriber-statements-best-practices-and-tips/): Prescriber statements have become one of the most valuable tools a pharmacy can use when needing to appeal claims found to be discrepant for a variety of reasons. They commonly take the form of a letter written by the prescriber to the PBM confirming, clarifying, or validating a prescription filled by your pharmacy. While every
- [CMS Updates HIV PrEP Supply Fee Code, Effective 01/01/2025](https://paasnational.com/cms-updates-hiv-prep-supply-fee-code-effective-01-01-2025/): In December 2024, PAAS National® brought you the Medicare Part B Coverage of HIV PrEP Newsline article which provided an in-depth look into appropriately billing HIV PrEP medications to Medicare Part B. The original shift from billing these medications from Medicare Part D to Part B was effective just a few months ago (September 30,
- [2024-2025 Self-Audit Series #11: Controlled Substance Prescriptions](https://paasnational.com/2024-2025-self-audit-series-11-controlled-substance-prescriptions/): The opioid epidemic continues to make controlled substance prescriptions an increased focus for PBM audits. The potential for fraud, diversion, overdoses, and abuse remains high and pharmacies must stay vigilant when dispensing these prescriptions. Due to federal and state requirements, controlled substance prescriptions have an increased risk of audit discrepancies. When found discrepant, PBMs typically
- [New Tool on PAAS Portal - DMEPOS Article Series 2024](https://paasnational.com/new-tool-on-paas-portal-dmepos-article-series-2024/): PAAS National® wrote a DMEPOS article series this year, which includes seven articles to be proactive in preventing Medicare Part B audits. We recently combined these articles into one tool for easy reference and review with your staff. The 2024 DMEPOS Article Series includes: Diabetic Test Strips Nebulizer Solutions Ostomy Supplies Surgical Dressings Urological Supplies (Intermittent Catheters)
- [Understanding the Medicare Prescription Payment Plan (MPPP or M3P): What You Need to Know](https://paasnational.com/understanding-the-medicare-prescription-payment-plan-mppp-or-m3p-what-you-need-to-know/): As part of the Inflation Reduction Act, all Medicare prescription drug plans (Medicare Part D plans) – including both standalone Medicare prescription drug plans and Medicare Advantage (MA) plans with prescription drug coverage - will be required to offer the Medicare Prescription Payment Plans (MPPP or M3P). This option allows patients to manage their copays
- [Reap the Benefits of the PAAS National® Newsline Archive](https://paasnational.com/reap-the-benefits-of-the-paas-national-newsline-archive/): Did you know that you can save time by searching past Newsline articles to find answers to your common questions? In fact, the Newsline archive offers articles going back to 2016! The search feature makes it simple to find that one article you know you read a while ago, but can’t seem to remember what
- [Adjusting Quantity or Days’ Supply Disproportionately Will Cost You!](https://paasnational.com/adjusting-quantity-or-days-supply-disproportionately-will-cost-you/): PAAS National® wants to emphasize the importance of submitting the correct days’ supply on claims. We see many audit results that could have been avoided had the pharmacy addressed the initial rejection and not bypassed the plan limit. A prevention strategy is important because these discrepancies are often difficult to appeal successfully. Pharmacy employees should
- [New Year, New Insurance, New Formularies!](https://paasnational.com/new-year-new-insurance-new-formularies/): With the new year approaching fast, many pharmacies are about to face the tedious task of getting patients’ new insurance cards (and dealing with changing formularies, copays and deductibles). As onerous as that can be, your pharmacy should consider ... Become an audit assistance member today to continue reading this article. As a member, you’ll
- [International Crime Ring Fraudulently Bills Insurers for Over $1 Billion in Telehealth Scheme](https://paasnational.com/international-crime-ring-fraudulently-bills-insurers-for-over-1-billion-in-telehealth-scheme/): In a fraud scheme that could be straight out of a made-for-TV movie, a U.S. citizen, acting as the ringleader in Russia, orchestrated a complex fraud using multiple accomplices. The operation defrauded private insurers by submitting fraudulent prescriptions through purported telemedicine visits. While the Department of Justice announced charges against the defendants last November, seven
- [Matching NDCs Help Keep the Audits at Bay](https://paasnational.com/matching-ndcs-help-keep-the-audits-at-bay/): Billing the wrong NDC can correlate to potential audit issues, ranging from recoupments on claims to risking contract termination. In fact, poor performance on invoice audits due to the pharmacy billing the incorrect NDC (in relation to the NDC dispensed), is a leading reason pharmacy contracts get terminated. This issue can be mitigated by ...
- [A New Way to Administer Epinephrine – Introducing neffy®](https://paasnational.com/a-new-way-to-administer-epinephrine-introducing-neffy/): ARS Pharmaceuticals Operations has recently introduced neffy® 2 mg, the first and only FDA-approved needle-free way to administer epinephrine. neffy® is a nasal spray used for emergency treatment of severe allergic reactions in adult and pediatric patients who weigh at least 66 pounds (30 kg). Per DailyMed, “the recommended dosage of neffy® is one spray
- [Medicare Part B Coverage of HIV PrEP](https://paasnational.com/medicare-part-b-coverage-of-hiv-prep/): As of September 30th, 2024 there was an industry shift from billing HIV Pre-Exposure Prophylaxis therapy (PrEP) from Medicare Part D to Medicare Part B. This shift to Part B coverage falls under section 1861(ddd)(1) of the Social Security Act using the “additional preventative services” benefit. Due to the high cost of HIV PrEP medications,
- [Forteo® Package Size Update – Are You Billing the Correct Cost?](https://paasnational.com/forteo-package-size-update-are-you-billing-the-correct-cost/): Forteo® (teriparatide injection) is a parathyroid hormone analog (PTH 1-34) used in the treatment of osteoporosis, specifically for postmenopausal women at high risk for fractures, men with primary or hypogonadal osteoporosis, and individuals with osteoporosis associated with sustained glucocorticoid therapy. It is designed to increase bone mass and reduce fracture risk in patients who have
- [Why the Unit of Measure Matters in Audits: A Small Factor with Big Consequences](https://paasnational.com/why-the-unit-of-measure-matters-in-audits-a-small-factor-with-big-consequences/): A unit of measure (UOM) provides standards to define physical quantities. Without a UOM, a number is left open for interpretation, and while common sense often prevails for pharmacies, third-party auditors look for explicit instruction. With an ambiguous, or absent, UOM (primarily an issue with electronic prescriptions), an auditor may flag the claim as discrepant
- [2024 Self-Audit Series #10: Nasal and Oral Inhaler Prescriptions](https://paasnational.com/2024-self-audit-series-10-nasal-and-oral-inhaler-prescriptions/): Nasal and oral inhaler prescriptions are frequently targeted for audit by all PBMs. Not only have these medications increased in cost but are frequently billed incorrectly, creating the potential for easy recoupments. Pharmacy staff should be trained to accurately bill days’ supply for all inhalers. PAAS National® has created tools for our members to aid
- [NADAC Survey: What is It and Do I Need to Respond?](https://paasnational.com/nadac-survey-what-is-it-and-do-i-need-to-respond-2/): Pharmacies that receive a National Average Drug Acquisition Cost (NADAC) Survey frequently contact PAAS National® for information and guidance. While this survey remains voluntary, pharmacies may want to take a minute to understand what the survey is about. Become an audit assistance member today to continue reading this article. As a member, you’ll have access
- [Ask a PAAS Expert](https://paasnational.com/ask-a-paas-expert/): While PAAS National® prides itself on being audit experts, audit assistance is more than just reactive support when an audit notice arrives.
- [New Tool on PAAS Portal – Exceeding Days’ Supply Plan Limits for Unbreakable Packages](https://paasnational.com/new-tool-on-paas-portal-exceeding-days-supply-plan-limits-for-unbreakable-packages/): PAAS National® is continuously updating and creating new tools to help our members address common audit recoupment issues.
- [Billing Coupons for Medicare Part D Patients – When Is It Okay?](https://paasnational.com/billing-coupons-for-medicare-part-d-patients-when-is-it-okay/): The Office of Inspector General (OIG) has made it clear that using manufacturer coupon cards with federally funded programs is prohibited by Anti-Kickback Statutes.
- [Representative NDC on Electronic Prescriptions Do Not Infer Specificity](https://paasnational.com/representative-ndc-on-electronic-prescriptions-do-not-infer-specificity/): When electronic prescriptions were first introduced, they were supposed to be more convenient for patients and cause less errors at the pharmacy (due to the legible nature of the information being sent from the prescriber).
- [The Clock is Ticking: Complete Your Annual Training!](https://paasnational.com/the-clock-is-ticking-complete-your-annual-training/): It is that glorious time of year again! Time for staff to be occupied not only with the daily activities of billing and filling medications, but also occupied with cough/cold/flu season, vaccine administration, answering Medicare Part D open enrollment questions, and holiday closures.
- [2024 Self-Audit Series #9: Eye Drop Days’ Supply](https://paasnational.com/2024-self-audit-series-9-eye-drop-days-supply/): Billing the accurate days’ supply for eye drops can be challenging. Despite what is drilled into pharmacists during schooling, there is no industry standard for drops/mL, and PBMs often use their own specific conversion factors.
- [Avoid This Billing Pitfall with Your Medicare Part B Nebulizer Solution Claims](https://paasnational.com/avoid-this-billing-pitfall-with-your-medicare-part-b-nebulizer-solution-claims/): Correctly billing Medicare Part B can be tough. The Local Coverage Determinations and associated Policy Articles for each DMEPOS category, along with the Standard Documentation Requirements for All Claims Submitted to DME MACs, are filled with billing and documentation guidelines which suppliers must fully comprehend and follow to avoid claim chargeback.
- [Hundreds of Patient Information Requests for Medicare: What This Means for Your Pharmacy](https://paasnational.com/hundreds-of-patient-information-requests-for-medicare-what-this-means-for-your-pharmacy/): Pharmacy personnel are all tasked with keeping patient protected health information (PHI) secure.
- [Ensure Your Team Is Prepared for PBM Audits](https://paasnational.com/ensure-your-team-is-prepared-for-pbm-audits/): In an interview with Pharmacy Times at the National Association of Community Pharmacists 2024 Convention & Expo, Trent Thiede, PharmD, president of Pharmacy Audit Assistance Service (PAAS) International, discussed how pharmacy teams can remain prepared for audits from pharmacy benefit managers (PBMs).
- [Best Practices for Proactively Preventing PBM Audit Issues | NCPA 2024](https://paasnational.com/best-practices-for-proactively-preventing-pbm-audit-issues-ncpa-2024/): Pharmacy Benefit Managers (PBMs) routinely conduct audits on independent pharmacies with the stated goal of preventing fraud, waste, and abuse in medication dispensing.
- [Third Amendment to the PREP Act Expiring Soon!](https://paasnational.com/third-amendment-to-the-prep-act-expiring-soon/): As previously discussed in the April 2024 Newsline article, New COVID-19 Booster Dose & The Final Frontier of the PREP Act, the Public Readiness and Emergency Preparedness Act (PREP Act) will expire as of December 31st, 2024, meaning the liability protections that enabled pharmacists, pharmacy interns, and pharmacy technicians to independently administer vaccines by means of the PREP Act will no longer exist.
- [Understanding Biologic Substitutions – New Tool Available!](https://paasnational.com/understanding-biologic-substitutions-new-tool-available/): Our PAAS National® analyst team developed a new tool to assist pharmacies with biologic substitutions. Understanding when to substitute and what to substitute with can be complicated.
- [Boost Your Bottom Line with In-Home Preventative Vaccine Administration](https://paasnational.com/boost-your-bottom-line-with-in-home-preventative-vaccine-administration/): As some may recall, the Centers for Medicare & Medicaid Services (CMS) rolled out a program back in 2021 where pharmacies were eligible to receive additional reimbursement for administering COVID-19 vaccinations to certain Medicare homebound patients (see October 2021 PAAS Newsline article, COVID-19 Vaccine Administration Audit Risk).
- [U.S. Government Alleges Counterfeit HIV Drugs Hiding in Pharmacy-to-Pharmacy Purchases](https://paasnational.com/u-s-government-alleges-counterfeit-hiv-drugs-hiding-in-pharmacy-to-pharmacy-purchases/): PAAS National® previously alerted pharmacies to a large-scale counterfeit HIV medication scam in our April 2022 article Know Your Distributors: Gilead Confiscates Phony HIV Medication where criminal enterprises routed black market and counterfeit HIV medications through the secondary wholesaler market (the 2022 Gilead lawsuit is referred to as Gilead I). In a new lawsuit filed ...
- [Walgreens $107 Million Settlement for False Claims Act Violations](https://paasnational.com/walgreens-107-million-settlement-for-false-claims-act-violations/): A recent Department of Justice press release outlined a settlement with Walgreens for nearly $107 million for False Claims Act violations related to claims billed to government programs that were never dispensed.
- [FDA Proposed Guidance for Biosimilar Updates](https://paasnational.com/fda-proposed-guidance-for-biosimilar-updates/): Over the last 10 years, biologics have transformed the treatment of many illnesses like chronic bowel disease, kidney disease, arthritis and cancer and they are the fastest growing class of medications in the United States.
- [Self-Audit Series #8: Compound Prescriptions](https://paasnational.com/self-audit-series-8-compound-prescriptions/): Compound prescriptions may not be a frequent occurrence for some pharmacies; however, those that do bill compounds must be aware of the audit risks.
- [Audit Risks: Medication Home Delivery](https://paasnational.com/audit-risks-medication-home-delivery/): Many independent pharmacies offer unique services to their patients, such as house charge accounts and medication delivery, to provide a better customer experience.
- [California Pharmacy Charged in $300 Million Medicaid Fraud Scheme](https://paasnational.com/california-pharmacy-charged-in-300-million-medicaid-fraud-scheme/): The US Attorney’s Office for the Central District of California recently issued a press release outlining charges against a pharmacist for the submission of more than $300 million in fraudulent claims to the state Medicaid Program (Medi-Cal) for medications that were not medically necessary, where drugs were not dispensed to patients, and where prescriptions were obtained through illegal kickbacks.
- [Is It Time to Purge? Understanding Record Retention Requirements](https://paasnational.com/is-it-time-to-purge-understanding-record-retention-requirements/): The majority of prescriptions filled by pharmacies are based off of an electronically-sent prescription, or “e-script” - 94% according to a 2021 Surescripts National Progress Report to be exact.
- [How to Submit Your Audit Documents for an Effective Review](https://paasnational.com/how-to-submit-your-audit-documents-for-an-effective-review/): PAAS National® analysts continue to see an increasing amount of PBM audits demanding large audit volumes of documents for reviews.
- [OptumRx® Provider Manual Updates May Shift Audits – Especially LTC](https://paasnational.com/optumrx-provider-manual-updates-may-shift-audits-especially-ltc/): OptumRx® updates their Provider Manual several times throughout the year and publishes the full version on its publicly available webpage.
- [Insulin Pens: Understanding Dosing Increments and Audit Risks](https://paasnational.com/insulin-pens-understanding-dosing-increments-and-audit-risks/): PAAS National® continues to see auditors flag insulin pen prescriptions for containing a dosage that does not align with the product.
- [What to Do (and Not Do) When Your Days’ Supply is Rejected](https://paasnational.com/what-to-do-and-not-do-when-your-days-supply-is-rejected/): Insurance companies require pharmacies to bill an accurate days’ supply based on mathematical calculations from the directions.
- [Medicare and Vaccine Billing: What You Need to Know](https://paasnational.com/medicare-and-vaccine-billing-what-you-need-to-know/): Pharmacies need to be aware of the risks of billing claims [to Medicare B/D] for patients under a Medicare Part A stay.
- [Scare Away the Unwanted: Four Facility Access Controls You Need!](https://paasnational.com/scare-away-the-unwanted-four-facility-access-controls-you-need/): Safeguarding the pharmacy’s Protected Health Information (PHI) is critical.
- [Caremark® Continues to Recover Payments for Unapproved Coupons](https://paasnational.com/caremark-continues-to-recover-payments-for-unapproved-coupons/): PAAS National® continues to see pharmacies face full recoupment on claims that are processed to coupons and copay cards in violation of Caremark’s® policy found in section 3.03.03 of the 2024 Pharmacy Provider Manual.
- [Avoid OptumRx® Double Chargeback Pitfalls - Review Your Days’ Supply](https://paasnational.com/avoid-optumrx-double-chargeback-pitfalls-review-your-days-supply/): OptumRx® has employed a new strategy to recoup more money on your pharmacy claims. Often upon an audit, if a pharmacy submitted an incorrect days’ supply, the PBM will re-adjudicate the claim with the correct days’ supply.
- [Rethink Corrective Action Plans](https://paasnational.com/rethink-corrective-action-plans/): PAAS National® analysts continue to see PBMs demand pharmacies complete formal Corrective Action Plans (CAPs) in response to negative audit outcomes; particularly from MedImpact, OptumRx, and Caremark.
- [Unveiling a Health Care Fraud and Illegal Black-Market Conspiracy](https://paasnational.com/unveiling-a-health-care-fraud-and-illegal-black-market-conspiracy/): The Department of Justice recently announced the sentencing for a California (CA) pharmacy owner and their co-conspirator for submitting fraudulent claims to Medicare and CA Medicaid for prescription drugs that were never dispensed to beneficiaries.
- [What FWA and HIPAA Compliance Elements are Necessary for Interns, Job Shadows, Floating Staff, Cashiers and Delivery Drivers?](https://paasnational.com/what-fwa-and-hipaa-compliance-elements-are-necessary-for-interns-job-shadows-floating-staff-cashiers-and-delivery-drivers/): Safeguarding the pharmacy’s Protected Health Information (PHI) is a MUST for all staff expected to come in contact with this sensitive information.
- [Quantity Written vs Quantity Dispensed - Are You Covered?](https://paasnational.com/quantity-written-vs-quantity-dispensed-are-you-covered/): PAAS National® analysts continue to see audit results flagging “unauthorized refills” or “excessive quantity billed”.
- [Drug Substitution Questions: Januvia®, Zituvio® and sitagliptin](https://paasnational.com/drug-substitution-questions-januvia-zituvio-and-sitagliptin/): PAAS National® analysts are receiving numerous inquiries regarding the substitution of Januvia®, Zituvio® and sitagliptin.
- [2024 Self-Audit Series #7: Migraine Medications](https://paasnational.com/2024-self-audit-series-7-migraine-medications/): In recent years, there has been a notable increase in the number of medications prescribed for migraine prevention and treatment. This increase leads to additional audit risks.
- [Flu Shot Season - Are You Prepared?](https://paasnational.com/flu-shot-season-are-you-prepared/): Flu shot season is just around the corner and PAAS National® wants to make sure you reduce your risk of audit recoupments. As busy as the flu season can be, it is important to follow the best practices and PAAS tips below to ensure you have all documentation in place.
- [2024 DMEPOS Series #7: Therapeutic Shoes for Diabetics](https://paasnational.com/2024-dmepos-series-7-therapeutic-shoes-for-diabetics/): Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements.
- [Back to School: How to Ace EpiPen® Billing and Avoid an Audit  ](https://paasnational.com/back-to-school-how-to-ace-epipen-billing-and-avoid-an-audit/): PAAS National® has seen an increase in prescription validation requests and audits for EpiPen® and, with back-to-school in full swing, we want all pharmacy employees to be aware of potential billing issues for this life-saving medication.
- [PBM Audits on Ozempic®: 5 Common Discrepancies Revealed](https://paasnational.com/pbm-audits-on-ozempic-5-common-discrepancies-revealed/): Popularity for GLP-1 medications, like Ozempic®, continues to grow and, consequently, PAAS National encounters these drugs on PBM audits frequently.
- [Audit Risk: Prescriber Scope of Practice and Treating Self or Family](https://paasnational.com/audit-risk-prescriber-scope-of-practice-and-treating-self-or-family/): Everyone knows that PBMs do not perform “random” audits, nor do they select “random” claims in these audits.
- [Nondiscrimination in Health Programs and Activities – Cultural Competency Training is a Must!](https://paasnational.com/nondiscrimination-in-health-programs-and-activities-cultural-competency-training-is-a-must/): Earlier this year the Office for Civil Rights (OCR) released the 2024 Final Rule under Section 1557 of the Affordable Care Act (ACA), reestablishing many of the 2020 Finale Rule protections that were removed by the prior administration.
- [2024 National Health Care Fraud Takedown](https://paasnational.com/2024-national-health-care-fraud-takedown/): On June 27th the U.S. Department of Justice (DOJ) issued a press release outlining a National Health Care Fraud Enforcement Action that resulted in 193 defendants charged, including doctors, nurses and pharmacists, and over $2.75 billion in false claims.
- [The Need for Clarification on Prescription Labels](https://paasnational.com/the-need-for-clarification-on-prescription-labels/): Pharmacy staff frequently receive prescriptions from prescribers that lack (or are missing) complete quantities or instructions for use. Clarifying these details before dispensing can help prevent audit discrepancies.
- [Are PBM Regulations Being Enforced by Your State? Let Your Voice Be Heard!](https://paasnational.com/are-pbm-regulations-being-enforced-by-your-state-let-your-voice-be-heard/): When PBMs violate state law, pharmacies need to scream from the mountain tops. Get the ball rolling by filing a complaint with your state regulators.
- [Liraglutide Injection Marks Debut as First Authorized Generic GLP-1 Product](https://paasnational.com/liraglutide-injection-marks-debut-as-first-authorized-generic-glp-1-product/): In late June, Teva Pharmaceuticals launched the first “generic” GLP-1 (Glucagon-Like-Peptide-1) receptor agonist in the United States, known as Liraglutide injection (6 mg/mL).
- [2024 DMEPOS Series #6: Immunosuppressive Drugs for Transplant](https://paasnational.com/2024-dmepos-series-6-immunosuppressive-drugs-for-transplant/): Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements.
- [DAW 8: Documentation When the Generic is Not Available](https://paasnational.com/daw-8-documentation-when-the-generic-is-not-available/): DAW code billing on multi-source brand medications is a frequent audit target for PBMs due to their potential higher cost, change in pharmacy reimbursement, and impact on patient copays. PAAS National® recommends ...
- [Do The Math and Avoid the Recoupment](https://paasnational.com/do-the-math-and-avoid-the-recoupment/): Proper mathematical calculations are critical to billing prescriptions correctly. The action of translating directions on the prescription into a mathematical equation seems simple, but PAAS National® analysts see claims billed with incorrect days’ supply every day!
- [2024 Self-Audit Series #6: Return to Stock](https://paasnational.com/2024-self-audit-series-6-return-to-stock/): PAAS National® analysts continue to see pharmacies face recoupment on audits due to return to stock violations.
- [The Double Threat: Ransomware Attack Followed by HIPAA Non-Compliance Settlement](https://paasnational.com/the-double-threat-ransomware-attack-followed-by-hipaa-non-compliance-settlement/): Imagine getting a papercut then moments later, cleansing your hands with alcohol hand sanitizer—you can almost feel the instantaneous sting the alcohol causes in the fresh wound. Not only are you subjected to the initial affliction, but also the second round of pain from the alcohol in the wound.
- [What’s New with Prescription Validation Requests in 2024?](https://paasnational.com/whats-new-with-prescription-validation-requests-in-2024/): In the PAAS National® January 2024 Newsline article PBM Validation Requests Rose 123% in 2023 – What You Need to Know, we discussed the PBM trends we saw in 2023. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2024 for comparison.
- [How to Safeguard Your Pharmacy from Fraudulent Electronic Prescriptions](https://paasnational.com/how-to-safeguard-your-pharmacy-from-fraudulent-electronic-prescriptions/): PAAS National® has recently assisted pharmacies who received fraudulent electronic prescriptions from prescribers that had their electronic prescribing credentials hacked or stolen.
- [2024 Self-Audit Series #5: Topical Prescriptions](https://paasnational.com/2024-self-audit-series-5-topical-prescriptions/): Topical medications are easy audit targets, especially with the rising costs of some of these medications.
- [Ensuring Audit Readiness: What PBMs Look for in Signature Logs and Proof of Delivery](https://paasnational.com/ensuring-audit-readiness-what-pbms-look-for-in-signature-logs-and-proof-of-delivery/): One of the most common questions PAAS National® receives from our members is: what are the requirements for audits when signature logs are requested.
- [Diabetic Test Strip Authorized Distributors](https://paasnational.com/diabetic-test-strip-authorized-distributors/): Independent pharmacies continue to receive threatening letters from LifeScan and an affiliated law firm on a monthly basis.
- [Metformin HCl ER – Audit Considerations](https://paasnational.com/metformin-hcl-er-audit-considerations/): Unfortunately, the cost difference can be significant, leading to an increased risk for audit - especially when a patient is taking Glumetza® or Fortamet®.
- [Auditors Are Drawn to Santyl® Like Moths to a Flame](https://paasnational.com/auditors-are-drawn-to-santyl-like-moths-to-a-flame/): Summer is here and so are the bugs! While mosquitos, gnats, moths and the like have next to nothing to do with Santyl® ointment for debriding chronic dermal ulcers and severely burned areas, the visualization of auditors being drawn to claims for Santyl® ointment being akin to moths (or other bugs) being drawn to a flame is a parallel not to be ignored.
- [Proper Billing of Nayzilam® and Valtoco® Nasal Sprays](https://paasnational.com/proper-billing-of-nayzilam-and-valtoco-nasal-sprays/): If your patient is prescribed Nayzilam® or Valtoco®, the perplexing billing opens the door for easy recoupments from PBMs.
- [NEW Dispense as Written (DAW) Code Revealed](https://paasnational.com/new-dispense-as-written-daw-code-revealed/): Chances are you have come across a claim or two (or several thousand!) with a DAW code of 1, 2, or 9. Pharmacy staff are usually knowledgeable about when to use these DAW codes – that a DAW 1 may be appropriate to use when the prescriber does not authorize generic substitution on a multi-source brand, a DAW 2 when the patient requested the brand name, and a DAW 9 when the plan explicitly indicates the brand name product is preferred.
- [On-Demand Webinar: Cybersecurity Considerations for Community Pharmacies](https://paasnational.com/on-demand-webinar-cybersecurity-considerations-for-community-pharmacies/): On May 8, 2024, PAAS National® hosted a webinar: Cybersecurity Considerations for Community Pharmacies.
- [The Different Cyclosporine Eye Drops That Could Cause Audit Trouble](https://paasnational.com/the-different-cyclosporine-eye-drops-that-could-cause-audit-trouble/): Cyclosporine eye drops are used to increase tear production in individuals with certain eye conditions and dry eye disease.
- [Independent Pharmacies are NOT Safe from Cyberattacks](https://paasnational.com/independent-pharmacies-are-not-safe-from-cyberattacks/): Have you ever had your credit card stolen, lost your wallet, or misplaced your social security card?
- [Commercial Claims Reimbursed through Embedded GoodRx® Discount Cards](https://paasnational.com/commercial-claims-reimbursed-through-embedded-goodrx-discount-cards/): Pharmacies have been reaching out to PAAS National® with concerns about claims being reimbursed through an embedded discount card (e.g., GoodRx®) rather than a patient’s commercial insurance plan benefit.
- [Missing PBM Audit Notifications: How Are They Supposedly Sent?](https://paasnational.com/missing-pbm-audit-notifications-how-are-they-supposedly-sent/): At times, pharmacies fail to receive audit notifications, even though PBMs record them as “successfully" delivered. Thus, understanding how PBMs communicate with pharmacies can be beneficial.
- [2024 Self-Audit Series #4: Transferred Prescriptions](https://paasnational.com/2024-self-audit-series-4-transferred-prescriptions/): Making sure your transferred prescriptions are complete can be one of the easiest audit recoupments to prevent.
- [OptumRx Continues to Cause Headaches!](https://paasnational.com/optumrx-continues-to-cause-headaches/): PBMs monitor, and flag, migraine medications due to excessive cost, quantities submitted, days’ supply (and/or frequency of refills) and vague instructions.
- [Pharmacy Owner’s Involvement in Fraud Scheme Leads to 4-Year Prison Sentence](https://paasnational.com/pharmacy-owners-involvement-in-fraud-scheme-leads-to-4-year-prison-sentence/): The Department of Justice recently announced the sentencing for a New York pharmacy owner. A four-year prison term, three years extended supervision, and paying back restitution of more than $6 million dollars, is the outcome for this owner based on his involvement in a Medicare and Medicaid fraud scheme.
- [Audit Risk: Billing DAW 1 Unnecessarily](https://paasnational.com/audit-risk-billing-daw-1-unnecessarily/): In a time where every aspect of prescriptions is scrutinized, PAAS National® wants to ensure you don’t forget simple filling and billing practices; in this case, using DAW 1 appropriately.
- [Diagnosis Restricted? Documentation Required!](https://paasnational.com/diagnosis-restricted-documentation-required/): PAAS National® is starting to see more audit recoupments on claims where a diagnosis code was required at adjudication but there was no documentation on the hardcopy to support the diagnosis code billed.
- [2024 DMEPOS Series #4: Surgical Dressings](https://paasnational.com/2024-dmepos-series-4-surgical-dressings/): This DMEPOS series is intended to help you understand these complexities and gather the needed documents. In particular, you should be able to show the following if audited on surgical dressings...
- [Do I Need to Consider Beyond Use Dating for Multi-dose Vial Medication?](https://paasnational.com/do-i-need-to-consider-beyond-use-dating-for-multi-dose-vial-medication/): The answer is YES! Multi-Dose Vials (MDV) for injection have Beyond Use Dates (BUD) that need to be followed.
- [Why You Should Care About PBM Provider Manuals (and Where to Find Them)](https://paasnational.com/why-you-should-care-about-pbm-provider-manuals-and-where-to-find-them/): Whether your pharmacy contracts directly with a PBM or the agreements are negotiated through a Pharmacy Services Administrative Organization (PSAO), the terms and conditions within the agreements are just the beginning of a pharmacy’s obligations.
- [OptumRx Targeting Medications Requiring Dispensing in Original Containers](https://paasnational.com/optumrx-targeting-medications-requiring-dispensing-in-original-containers/): Recent audit results coming into PAAS National® are showing OptumRx auditors have their sights set on several medications that are required to be dispensed in the original container.
- [Fraud, Waste, and Abuse Compliance Programs Are Not Optional](https://paasnational.com/fraud-waste-and-abuse-compliance-programs-are-not-optional/): FWA Training and OIG/GSA exclusion checks are not enough to be compliant as they do not constitute a compliance program.
- [On-demand webinar: Cybersecurity Considerations for Pharmacies](https://paasnational.com/on-demand-webinar-cybersecurity-considerations-for-pharmacies/): On May 8, 2024 PAAS National® hosted “Cybersecurity Considerations for Pharmacies” webinar. In a world where threats lurk around every digital corner, safeguarding sensitive information has never been more crucial.
- [Introducing PAAS Cybersecurity Training](https://paasnational.com/introducing-paas-cybersecurity-training/): PAAS National® is excited to announce the launching of a new training series to FWA/HIPAA Compliance Program members: PAAS Cybersecurity Training.
- [LIVE Webinar:  Cybersecurity Considerations for Pharmacies](https://paasnational.com/live-webinar-cybersecurity-considerations-for-pharmacies/): In a world where threats lurk around every digital corner, safeguarding sensitive information has never been more crucial. Join PAAS National on Wednesday, May 8th from 2:00-2:45pm CT for a LIVE webinar on Cybersecurity Considerations for Pharmacies.
- [OptumRx Auditing for Medical Supplies Billed Under Medicare Part D](https://paasnational.com/optumrx-auditing-for-medical-supplies-billed-under-medicare-part-d/): In March 2024, PAAS National® analyst assisted nearly 100 pharmacies with desk audits from OptumRx requesting documentation related to claims for medical supplies (primarily alcohol swabs) that were processed by OptumRx under the Medicare Part D benefit.
- [Does My Pharmacy Really Need Cultural Competency Training?](https://paasnational.com/does-my-pharmacy-really-need-cultural-competency-training-2/): Pharmacies are no stranger to the requirements of completing annual Medicare Fraud, Waste, and Abuse training, which is a very clear requirement created by Medicare Part D and MAPD statutes. Because CMS holds PDPs and MAPDs responsible, PBMs often ask for the pharmacy’s FWA training during onsite audits. On the contrary, cultural competency training isn’t something PBMs regularly ask for. In a world where pharmacy employees are already spread thin, is completing cultural competency training truly necessary?
- [Philadelphia Pharmacy Employees Charged for Drug Diversion and Fraudulent Billing Practices](https://paasnational.com/philadelphia-pharmacy-employees-charged-for-drug-diversion-and-fraudulent-billing-practices/): A years-long investigation of the top retail pharmacy purchasing oxycodone in Pennsylvania has come to resolution.
- [2024 Self-Audit Series #3: Invoice Audits](https://paasnational.com/2024-self-audit-series-3-invoice-audits/): The number of invoice audits continues to rise from Medicaid, and PBMs, across the board. This investigational audit is a way to potentially identify false or phantom claims. Auditors will reconcile the claims billed by a pharmacy during a certain timeframe, with the purchases made.
- [2024 DMEPOS Series #3: Ostomy Supplies](https://paasnational.com/2024-dmepos-series-3-ostomy-supplies/): This DMEPOS series is intended to help you understand these complexities and gather the needed documents. In particular, you should be able to show the following if audited on ostomy supplies:
- [Audit Preparedness in Long-Term Care Claims: Implementing Proactive Measures](https://paasnational.com/audit-preparedness-in-long-term-care-claims-implementing-proactive-measures/): The practice of LTC pharmacy is different – look no farther than the dichotomy between prescriptions and orders. While state laws may be vague or unclear, resulting in pharmacists using professional judgement, PBMs have their own requirements. Do PBM Provider Manuals (and auditors) view LTC differently? The answer may surprise you ...
- [V-Go® All-In-One Insulin Delivery Patch](https://paasnational.com/v-go-all-in-one-insulin-delivery-patch/): The V-Go® all-in-one insulin delivery patch is a disposable device approved for use in patients with Type 2 diabetes.
- [The Alarming Toll of HIPAA Breaches: Over 41 Million Individuals Affected in 2022](https://paasnational.com/the-alarming-toll-of-hipaa-breaches-over-41-million-individuals-affected-in-2022/): Each year, the Health and Human Services Office for Civil Rights (OCR) composes detailed reports on HIPAA compliance and breaches of unsecured Protected Health Information (PHI) and delivers them to Congress.
- [Distribution Required: Medicare Prescription Drug Coverage and Your Rights (CMS-10147)](https://paasnational.com/distribution-required-medicare-prescription-drug-coverage-and-your-rights-cms-10147/): When a pharmacy receives a rejection for a claim not being covered by Medicare Part D, the pharmacy must provide the patient with the CMS-10147 form, also known as the Medicare Prescription Drug Coverage and Your Rights.
- [Are You Prepared for a Spravato® Audit?](https://paasnational.com/are-you-prepared-for-a-spravato-audit/): PAAS National® has seen audits with full claim recoupments being requested as a result of missing dosage and frequency instructions, as well as incomplete dispensing records. To minimize the risk of a Spravato® claim being recouped during an audit, consider the following PAAS tips ...
- [2023 Health and Human Services Language Access Plan Released: New Plan, Same Goal](https://paasnational.com/2023-health-and-human-services-language-access-plan-released-new-plan-same-goal/): Equal access to health care is far from a new topic, dating back to Title VI of the Civil Rights Act of 1964. In recent years, there has been a noticeable increase in enforcement.
- [Documentation is Essential for Prescription Quantity Changes](https://paasnational.com/documentation-is-essential-for-prescription-quantity-changes/): Anytime a pharmacy dispenses a quantity different than what the prescriber ordered, there should be a reason documented on the prescription for the decreased or increased quantity.
- [New COVID-19 Booster Dose & The Final Frontier of the PREP Act](https://paasnational.com/new-covid-19-booster-dose-the-final-frontier-of-the-prep-act/): On February 28th, the CDC endorsed an additional updated 2023-2024 COVID-19 vaccine dose for adults 65 years or older due to the increased risk of serious COVID-19 outcomes in that patient population.
- [Required: Proof of Patient Copay Collection](https://paasnational.com/required-proof-of-patient-copay-collection/): All PBM agreements contain language requiring pharmacies to collect copays and be able to prove those copays were collected if audited.
- [Why Do You Need a HIPAA Risk Analysis? Ask Change Healthcare…](https://paasnational.com/why-do-you-need-a-hipaa-risk-analysis-ask-change-healthcare/): If you have not been affected by the Change Healthcare cyberattack, you have no doubt heard about the sinister actions of the ALPHV Blackcat ransomware gang and the resulting chaos from their February data breach they caused.
- [Announcing the PAAS Rx Days’ Supply Calculator App](https://paasnational.com/announcing-the-paas-rx-days-supply-calculator-app/): Pharmacy staff face numerous challenges in managing prescriptions effectively. Manually calculating the appropriate quantity or days’ supply of medications can be time-consuming and prone to errors, creating the potential for PBM audits.
- [2024 DMEPOS Series #2: Nebulizer Solutions](https://paasnational.com/2024-dmepos-series-2-nebulizer-solutions/): Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements.
- [Caremark Notice of Breach – Aberrant Practices and Trends](https://paasnational.com/caremark-notice-of-breach-aberrant-practices-and-trends/): PAAS National® analysts have recently assisted multiple pharmacies that received faxed notifications from Caremark that their pharmacy has “breached” the PBM Agreement by exceeding an arbitrary 25% threshold (by $ or # of claims) on the Aberrant Product List for their total claims dispensed in January 2024.
- [High AWP Omeprazole leads to $2.3M Medicaid Fraud Case](https://paasnational.com/high-awp-omeprazole-leads-to-2-3m-medicaid-fraud-case/): An Ohio pharmacist and owner of four pharmacies, along with a technician, have been found guilty by a federal jury for Medicaid fraud to the tune of $2.3M dollars.
- [2024 Self-Audit Series #2: DAW Codes](https://paasnational.com/2024-self-audit-series-2-daw-codes/): Prescriptions flagged for incorrect or invalid DAW codes is a discrepancy we have seen increase notably on PBM audit results.
- [Numerous Sumatriptan Formulations Cause Headaches for Pharmacies, & Potential Recoupments](https://paasnational.com/numerous-sumatriptan-formulations-cause-headaches-for-pharmacies-potential-recoupments/): Sumatriptan is FDA approved for the acute treatment of migraine headaches, with or without aura.
- [NDC Numbers: Not a Guarantee of FDA Approval](https://paasnational.com/ndc-numbers-not-a-guarantee-of-fda-approval/): A common misconception that pharmacies have is that if a product has an NDC (National Drug Code) number that means it is approved by the FDA – unfortunately, this is not the case.
- [Caremark Invoice Audits – Purchases from Other Pharmacies](https://paasnational.com/caremark-invoice-audits-purchases-from-other-pharmacies/): Caremark invoice audits continue to plague many pharmacies and often result in substantial audit findings and, occasionally, network termination.
- [Best Practices When Filling & Billing Afrezza®](https://paasnational.com/best-practices-when-filling-billing-afrezza/): Afrezza®, a rapid-acting insulin human inhalation powder for adults with either type 1 or type 2 diabetes mellitus, can cause confusion for prescribers, pharmacies, and patients alike.
- [Cybersecurity Incident at Change Healthcare – Documentation is Key to Reducing Audit Risk!](https://paasnational.com/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).
- [Bowel Prep Products – What Quantity and Days’ Supply to Bill?](https://paasnational.com/bowel-prep-products-what-quantity-and-days-supply-to-bill/): The most common PBM audit issue PAAS sees with bowel prep products is billing an incorrect days’ supply.
- [Qualified Medicare Beneficiary (QMB) Program](https://paasnational.com/qualified-medicare-beneficiary-qmb-program/): Pharmacies may bill prescriptions from time to time for patients with dual eligibility, possessing both Medicare and Medicaid benefits.
- [Early Refills of Titrated Medications Lead to Recoupments](https://paasnational.com/early-refills-of-titrated-medications-lead-to-recoupments/): Titration is a common practice for certain medications where prescribers start a patient on a low dose and gradually increase the amount over time to find what’s most effective.
- [Walgreens Reaches $360 Million Settlement with Humana Regarding Inflated Prescription Drug Prices](https://paasnational.com/walgreens-reaches-360-million-settlement-with-humana-regarding-inflated-prescription-drug-prices/): In January 2024, Walgreens and Humana reached a $360 million settlement to resolve ongoing lawsuits where Humana argued that Walgreens violated the PBM agreement by artificially inflating prescription drug prices for years.
- [Miebo™ Eye Drops – What is the Days’ Supply?](https://paasnational.com/miebo-eye-drops-what-is-the-days-supply/): Miebo™ is the first and only prescription eye drop used to treat dry eye syndrome by directly targeting tear evaporation. PAAS National® has fielded several calls regarding Miebo™ asking how to calculate the days’ supply.
- [2024 Self-Audit Series #1: Insulin Prescriptions](https://paasnational.com/2024-self-audit-series-1-insulin-prescriptions/): These articles can be an excellent training tool for new employees, and a great refresher for all pharmacy staff, to avoid audit discrepancies.
- [Continuous Glucose Monitor (CGM) Billing and Supply Allowance](https://paasnational.com/continuous-glucose-monitor-cgm-billing-and-supply-allowance/): CMS has issued an update on the Glucose Monitor - Policy Article effective as of January 1, 2024.
- [Be on the Lookout for Eye Drops Requiring Extra Billing Consideration](https://paasnational.com/be-on-the-lookout-for-eye-drops-requiring-extra-billing-consideration/): Correctly billing eye drops requires a little extra thought and consideration, but it does not have to be a daunting task. Follow these simple steps ...
- [Dosing Increments for Insulin Pens](https://paasnational.com/dosing-increments-for-insulin-pens/): While insulin pens allow ease and convenience for diabetic patients, they also come with increased audit risks, for a variety of reasons, including dosing.
- [2024 DMEPOS Series #1: Diabetic Test Strips](https://paasnational.com/2024-dmepos-series-1-diabetic-test-strips/): Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements.
- [Employer Pays $4.75 Million after Employee Stole, then Sold, Protected Health Information](https://paasnational.com/employer-pays-4-75-million-after-employee-stole-then-sold-protected-health-information/): While HIPAA training may feel tedious and appear to be a waste of time and payroll, it’s crucial not to take shortcuts when it comes to compliance!
- [Additional Audit Assistance Member Benefits](https://paasnational.com/additional-audit-assistance-member-benefits/): As we start 2024, keep in mind your Audit Assistance membership includes more than just assistance on audits and a monthly printed newsletter.
- [Insulin Substitution Review: Understanding Purple Book Terminology](https://paasnational.com/insulin-substitution-review-understanding-purple-book-terminology/): PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
- [Inventory Purchase Reminders for Successful Audits](https://paasnational.com/inventory-purchase-reminders-for-successful-audits/): With a 29% increase in PBM audits in 2023, PAAS National® wants to help you avoid PBM scrutiny, especially when it comes to drug procurement.
- [Addressing “Weird” Days’ Supply](https://paasnational.com/addressing-weird-days-supply/): e know that days’ supply should be billed based on the mathematically calculable directions, but what happens when the days’ supply does not fall in the easily calculable 30- or 90-day spectrum? What if it is “weird?”
- [Caremark Bulk Purchase Notification](https://paasnational.com/caremark-bulk-purchase-notification/): PAAS National® analysts continue to see a large volume of Caremark invoice audits. Remember that Caremark will only review aggregate purchases over the selected date range plus the 30 days prior to. If pharmacies want Caremark to consider purchases made prior to the selected date range, then there must be a “bulk purchase notification” on file in accordance with Section 8.05 of the Caremark Provider Manual.
- [Adapting to Change: Levemir<sup>®</sup> Phase Out and Its Implications for Pharmacies](https://paasnational.com/adapting-to-change-levemir-phase-out-and-its-implications-for-pharmacies/): In November 2023, Novo Nordisk® announced that it would be phasing out the company’s long-acting insulin, Levemir®, in the United States.
- [Best Practices for DAW Billing in Pharmacies](https://paasnational.com/best-practices-for-daw-billing-in-pharmacies/): In what should be a fairly straightforward process, proper DAW billing practices can be convoluted. Despite NCPDP guidance to standardize adjudication practices, PBMs do not always adopted these standards, leaving the pharmacy in a gray area of what proper DAW billing should look like.
- [Tip to Federal Agents Leads to Jail Time for Pharmacy Owner](https://paasnational.com/tip-to-federal-agents-leads-to-jail-time-for-pharmacy-owner/): The Department of Justice announced a Nebraska pharmacist, and owner of two pharmacies, was sentenced to two months of imprisonment, three years of supervised release, and ordered to pay restitution in the amount of $573,000.
- [DMEPOS Updated Refill Request and Affirmative Response Requirements](https://paasnational.com/dmepos-updated-refill-request-and-affirmative-response-requirements/): Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims. If you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems during an audit.
- [Don’t Cut Corners: Notations on Prescriptions](https://paasnational.com/dont-cut-corners-notations-on-prescriptions/): Not only are new medications frequently released to market, but also new strengths and formulations of existing medications.
- [FDA Issues Updates to iPLEDGE<sup>®</sup> REMS Program](https://paasnational.com/fda-issues-updates-to-ipledge-rems-program/): Isotretinoin capsules are FDA approved for the treatment of severe recalcitrant nodular acne in non-pregnant patients 12 years of age and older with multiple inflammatory nodules with a diameter of 5 mm or greater. Due to the risk of severe life-threatening birth defects and risk of embryo-fetal toxicity, isotretinoin is only available under the iPLEDGE® Risk Evaluation and Mitigation Strategy (REMS) program.
- [Law Enforcement Access to Protected Health Information – What’s Your Policy?](https://paasnational.com/law-enforcement-access-to-protected-health-information-whats-your-policy/): Understanding and adhering to the HIPAA Privacy Rule is required for covered entities who handle protected health information (PHI), but because the Privacy Rule was designed to be flexible, implementation of policies and procedures to meet the Privacy Rules can vary from covered entity to covered entity.
- [A Day in the Life of a PAAS National Analyst – Audits, Billing Questions and FWA/HIPAA support](https://paasnational.com/a-day-in-the-life-of-a-paas-national-analyst-audits-billing-questions-and-fwa-hipaa-support/): The PAAS Analyst team is made up of five pharmacists and three certified pharmacy technicians. Their job day in and day out is to be a member’s resource in:
- [Top 10 PAAS National Articles of 2023](https://paasnational.com/top-10-paas-national-articles-of-2023/): PAAS Audit Assistance members receive a monthly newsletter with new audit tactics and prevention tips. Review the top 10 articles of 2023.
- [2024 Fraud, Waste & Abuse and HIPAA Compliance Program Updates](https://paasnational.com/2024-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.
- [Major PBMs Announce “Cost Plus” Pharmacy Networks](https://paasnational.com/major-pbms-announce-cost-plus-pharmacy-networks/): In the fourth quarter of 2023, two of the “Big 3” PBMs announced that they will introduce new reimbursement methods for network pharmacies in the coming year(s) based on Cost Plus formulas in place of the typical AWP Minus terms.
- [Be Conscientious When Refusing to Dispense (or Bill Insurance)…](https://paasnational.com/be-conscientious-when-refusing-to-dispense-or-bill-insurance/): No pharmacy should be forced to dispense prescriptions below their acquisition cost.
- [Prescriber Statements for Successful Appeal](https://paasnational.com/prescriber-statements-for-successful-appeal/): One of the most common requirements for appealing audit discrepancies is to provide a signed statement from the prescriber to confirm, clarify, or validate a prescription.
- [2024 Update: CMS Mandatory E-Prescribing Requirements for Controlled Substances – Final Rule](https://paasnational.com/2024-update-cms-mandatory-e-prescribing-requirements-for-controlled-substances-final-rule/): The SUPPORT Act was created to address the opioid crisis in our nation. Section 2003 states that all Schedule II-V controlled substance prescriptions under Medicare Part D and Medicare Advantage plans (MA-PD) must be transmitted electronically.
- [Days’ Supply Considerations for Eye Medications](https://paasnational.com/days-supply-considerations-for-eye-medications/): PBM audits regularly target eye medications looking to recoup on claims for incorrect days’ supply or early refills.
- [PBM Prescription Validation Requests Rose 123% in 2023 – What You Need to Know](https://paasnational.com/pbm-prescription-validation-requests-rose-123-in-2023-what-you-need-to-know/): PAAS National® saw the number of validation requests/concurrent claim reviews more than double in 2023!
- [Painful Lessons: What You Should Know About Return to Stock Timeframes](https://paasnational.com/painful-lessons-what-you-should-know-about-return-to-stock-timeframes/): PBMs allow a limited amount of time for a prescription to be picked up or delivered to a patient before the claim must be reversed and the medication placed back into the pharmacy’s stock inventory.
- [Transfer Tragedy: A Timeworn PBM Target](https://paasnational.com/transfer-tragedy-a-timeworn-pbm-target/): It’s a tale almost as old as time - a patient’s medication is sent to one pharmacy only to have the patient decide they want it filled by your pharmacy instead.
- [Elixir Audit Notice Delivery Methods](https://paasnational.com/elixir-audit-notice-delivery-methods/): What is worse than receiving an audit notice? Receiving audit results which state “NRS - No Response to Audit Request” when the pharmacy never received the audit notice.
- [News Article with Protected Health Information Led to an $80,000 HIPAA Settlement](https://paasnational.com/news-article-with-protected-health-information-led-to-an-80000-hipaa-settlement/): According to a November 2023 press release from the Office for Civil Rights (OCR), Saint Joseph’s Medical Center (“Saint Joseph’s”) of New York state agreed to pay $80,000 and implement a corrective action plan in response to their unauthorized release of Protected Health Information (PHI).
- [Staying Compliant with House Charge Accounts](https://paasnational.com/staying-compliant-with-house-charge-accounts/): BMs require pharmacies to collect patient copayments in full and any deviation from that practice may be considered fraudulent behavior, with limited exceptions.
- [Unveiling a Multi-Million Dollar Fraud and Kickback Scheme](https://paasnational.com/unveiling-a-multi-million-dollar-fraud-and-kickback-scheme/): According to an August 18, 2023 press release from the Department of Justice (DOJ), a pharmacy operations manager and some co-conspirators have pled guilty to committing healthcare fraud and to paying illegal kickbacks for Medicare and Medicaid claims that were never dispensed to patients.
- [Zepbound (tirzepatide) Means Decreased Audit Risk…Right?](https://paasnational.com/zepbound-tirzepatide-means-decreased-audit-riskright/): , PAAS National® would like to take this opportunity to update our members on what PBM trends we have seen thus far, draw attention to the guidelines laid out by PBMs and regulations in which we can rely on, and give our thoughts on the current audit situation in the hopes of allowing you to make the most informed business decision.
- [Insufficient/Missing Clinical Notes Yield Audit Recoupments](https://paasnational.com/insufficient-missing-clinical-notes-yield-audit-recoupments/): PAAS National® analysts are seeing more prescriptions flagged for recoupment when insufficient or missing information is not verified with a valid clinical note.
- [Auditors Become Increasingly Stringent on Quantity and Unit of Measure Appeals](https://paasnational.com/auditors-become-increasingly-stringent-on-quantity-and-unit-of-measure-appeals/): You may recall the article "Quantity Changes Cause Audit Appeal Trouble " from the May 2023 Newsline. The article discusses how PAAS National® saw an increase in the number of discrepancies for “unauthorized” refills.
- [USP 800 Sets New “National Professional Standard”](https://paasnational.com/usp-800-sets-new-national-professional-standard/): Community pharmacies have been dispensing hazardous drugs long before the potential for harm (due to low dose, long term exposure) was known. Exposure to a hazardous drug is often inadvertent and unknown to the employee.
- [Avoiding MedImpact Recoupments for Bypassing Plan Limits](https://paasnational.com/avoiding-medimpact-recoupments-for-bypassing-plan-limits/): Pharmacies receive many rejections while billing claims throughout the day. Paying attention to these rejection messages is key to avoiding audit recoupments, which may occur years later.
- [Documentation Deep Dive: Meeting Auditors' Standards in DUR and SCC](https://paasnational.com/documentation-deep-dive-meeting-auditors-standards-in-dur-and-scc/): PAAS National® frequently sees claims audited that contain a clinical drug utilization review (DUR) or submission clarification code (SCC), particularly from Express Scripts and Prime Therapeutics.
- [Best Practices for Financial Hardship Waivers](https://paasnational.com/best-practices-for-financial-hardship-waivers/): PAAS National® analysts have noticed an increase in PBM audits focusing on copay collection. These audits requested a copy of the pharmacies’ policies and procedures addressing copay collection and financial hardship.
- [All Pharmacies Face Medicare Part A vs Part D Billing Risks, Especially Combo Shops](https://paasnational.com/all-pharmacies-face-medicare-part-a-vs-part-d-billing-risks-especially-combo-shops/): Pharmacies that service long-term care (LTC) and assisted living facilities (ALF) as well as retail patients, known as “Combo Shops”, may not be aware of the potential recoupment risks from Medicare. PAAS National® wants to inform our members of these risks and how to best avoid them.
- [PBM Audits: Letters to Patients for Prescription Verification](https://paasnational.com/pbm-audits-letters-to-patients-for-prescription-verification/): Pharmacies often see PBM audit letters requesting documentation to validate paid claims, but not very many see letters sent to their patients.
- [Avoid the Creon® Chargeback Catastrophe by Following THIS Billing Rule](https://paasnational.com/avoid-the-creon-chargeback-catastrophe-by-following-this-billing-rule/): Creon® is indicated for the treatment of exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions. Claims for these pancreatic enzymes find themselves on audits year after year, and the audit risk has just increased as ...
- [PAAS National® Announces USP 800 Compliance Program](https://paasnational.com/paas-national-announces-usp-800-compliance-program/): PAAS National® is excited to announce the USP 800 Compliance Program for community pharmacies. Developed by community pharmacists, PAAS brings you a community pharmacy tailored approach to USP 800 operational needs.
- [The Power of Clearly Communicated Sanction Policies in HIPAA Compliance](https://paasnational.com/the-power-of-clearly-communicated-sanction-policies-in-hipaa-compliance/): Adequate and thorough training is an essential component to all employee on-boarding and continued employment. One critical topic to discuss is sanctions, because the HIPAA Privacy and Security Rules both require sanction policies.
- [USP 800 - The Struggle is Real…](https://paasnational.com/usp-800-the-struggle-is-real/): Are you compliant with USP 800? While USP 800 became official on December 1, 2019, it was informational only and not compendially applicable.
- [Biosimilar Advancements: Understanding the Latest Updates on Humira® with Cyltezo® and Abrilada™](https://paasnational.com/biosimilar-advancements-understanding-the-latest-updates-on-humira-with-cyltezo-and-abrilada/): At the time our April 2023 Newsline article Biosimilar Adoption for Humira® in 2023 was published, eight FDA biosimilars for Humira had been approved, and five more were pending approval.
- [Audit Target: Linzess® Prescriptions](https://paasnational.com/audit-target-linzess-prescriptions/): PAAS National® analysts have noticed an increase in audits targeting Linzess®.
- [Potential HIPAA Violations Lead to $1.3 Million Settlement](https://paasnational.com/potential-hipaa-violations-lead-to-1-3-million-settlement/): According to a September 11, 2023 news release from the U.S. Department of Health and Human Services (HHS), “L.A. Care, the largest publicly operated health plan in the country paid $1,300,000 to settle” potential HIPAA Security Rule violations.
- [Calculating Days’ Supply – Pancreatic Enzymes](https://paasnational.com/calculating-days-supply-pancreatic-enzymes/): Auditors target pancreatic enzyme prescriptions like Creon® and Zenpep® due to high cost and ambiguous directions.
- [Albuterol HFA Inhaler Substitution Refresh](https://paasnational.com/albuterol-hfa-inhaler-substitution-refresh/): There have been many new albuterol HFA NDCs released since the June 2020 article, First AB-Rated Generic for Proventil® HFA Approved, and since albuterol inhaler substitutions require an extra level of consideration due to not all NDCs being equivalent, a refreshed chart was in order.
- [Specialty Pharmacy Paying the Price: $20 Million Settlement for Kickbacks and Copay Waivers](https://paasnational.com/specialty-pharmacy-paying-the-price-20-million-settlement-for-kickbacks-and-copay-waivers/): A September 30, 2023, Department of Justice press release outlined a recent settlement between the U.S. government and a specialty pharmacy based in Delaware.
- [You’ve Got Mail! Post-COVID-19 Mailing & Delivery Considerations](https://paasnational.com/youve-got-mail-post-covid-19-mailing-delivery-considerations/): After three years of a Public Health Emergency (PHE) due to COVID-19, the Department of Health and Human Services (HHS) allowed the PHE to expire May 11, 2023. With the end of the PHE came the end of most PBM concessions, including those made in relation to mailing and delivery of medications.
- [3…2…1…The Countdown is On to Complete Annual Fraud, Waste & Abuse Training](https://paasnational.com/321the-countdown-is-on-to-complete-annual-fraud-waste-abuse-training/): Now is the time to ensure staff complete their annual Fraud, Waste & Abuse and HIPAA Compliance training since the December 31st deadline will be here before we know it!
- [Fair Access for All: The Proposed Rule’s Potential to Strengthen Anti-Discrimination in Pharmacies](https://paasnational.com/fair-access-for-all-the-proposed-rules-potential-to-strengthen-anti-discrimination-in-pharmacies/): The Biden-Harris Administration is continuing to bolster the importance of equal access to health care and human services for individuals with disabilities through a new proposed rule.
- [Advances in Respiratory Syncytial Virus (RSV) Prevention](https://paasnational.com/advances-in-respiratory-syncytial-virus-rsv-prevention/): There are two RSV vaccines FDA-approved for people ages 60 years and older – AbrysvoTM and Arexvy®.
- [COVID-19 Resources](https://paasnational.com/covid19/): PAAS National® is proud to support you during these trying times and we want to thank you for your endurance, perseverance, and service to our communities.
- [$32 Million Kickback Scheme Involving Medicare and TRICARE](https://paasnational.com/32-million-kickback-scheme-involving-medicare-and-tricare/): According to an August 18, 2023 press release from the U.S. Attorney’s Office, District of New Jersey, a former president of a pharmacy business pleaded guilty to a scheme that violated the Federal Anti-Kickback statute.
- [PAAS Battles MedImpact for DAW 0 Reimbursement on Semglee®](https://paasnational.com/paas-battles-medimpact-for-daw-0-reimbursement-on-semglee/): MedImpact sent a memo to network pharmacies dated May 22, 2023, with the subject line Semglee-YFGN (Preferred U-100 Long Acting Insulin). For their participating Medicare Part D plans, MedImpact requested pharmacies to dispense Semglee® (YFGN) at the brand reimbursement.
- [[FREE PAAS Webinar] Awareness to Action: Initiating USP 800 Compliance in Community Pharmacies](https://paasnational.com/awareness-to-action-initiating-usp-800-compliance-in-community-pharmacies/): Join Vice President of PAAS National, Carmen Fusselman, PharmD as she discusses "Awareness to Action: Initiating USP 800 Compliance in Community Pharmacies" in a live webinar on October 12th at 10am CST.
- [NEW PAAS Resource - Printable Signature Logbook](https://paasnational.com/new-paas-resource-printable-signature-logbook/): Many pharmacies have made the switch to electronic signature log capture, but paper signature logs have not gone away.
- [OTC COVID-19 Test Prescribing Authority](https://paasnational.com/otc-covid-19-test-prescribing-authority/): Some pharmacies are wondering if they are allowed to continue prescribing OTC COVID-19 tests.
- [Breyna™ – The First FDA Approved Symbicort® Generic With a 0.1 Gram Problem](https://paasnational.com/breyna-the-first-fda-approved-symbicort-generic-with-a-0-1-gram-problem/): Breyna™, like Symbicort® is approved as a maintenance therapy for people with COPD and for asthma patients ages 6 and older.
- [Signature Required – Proving Patient Receipt](https://paasnational.com/signature-required-proving-patient-receipt/): The Public Health Emergency for COVID-19 ended on May 11, 2023, and PBMs notified pharmacies that they would once again be requiring signatures for proof of patient receipt of medications.
- [Use As Directed – What is Your Attack Plan?](https://paasnational.com/use-as-directed-what-is-your-attack-plan/): The top audit discrepancy year after year is invalid days’ supply or refill too soon – which are essentially the same issue.
- [Recent DEA Rule Change - Transferring Electronic Prescriptions for Controlled Substances for Initial Fill](https://paasnational.com/recent-dea-rule-change-transferring-electronic-prescriptions-for-controlled-substances-for-initial-fill/): The DEA published a couple rule changes recently which pharmacies need to be aware of. In the September 2023 Newsline, the updated rule regarding partial fills for controlled substances was discussed. The other recent change published in the Federal Register was titled, Transfer of Electronic Prescription for Schedules II-V Controlled Substances Between Pharmacies for Initial Filling.
- [Auditors’ Latest Trick for Flagging “Misfilled” Prescriptions](https://paasnational.com/auditors-latest-trick-for-flagging-misfilled-prescriptions/): PAAS National® analysts are noticing more prescriptions being flagged for recoupment based on “incorrect” instructions for use on the patient label. Pharmacies and PBM auditors have very different perspectives on what a “misfilled" prescription is.
- [An Easy Procedural Change That Will Prevent Recoupments](https://paasnational.com/an-easy-procedural-change-that-will-prevent-recoupments/): As previously reported in an April 2023 Newsline article, Prepare Yourselves! Onsite Audits Are Coming in Strong, PAAS National® saw a 300% increase in onsite audits in just the 3rd Quarter of 2022, and we have continued to see the number of audits, as well as the information requested in these audits, increase.
- [Utilizing the PAAS Audit Activity Tracker](https://paasnational.com/utilizing-the-paas-audit-activity-tracker/): While seemingly mundane, the PAAS National® Audit Activity Tracker can serve a very important purpose. While pharmacy personnel may use this tool to stay organized with various audits coming their way, this tool can also be used to defend the pharmacy should an audit go awry.
- [Podcast: A Deep Dive into LTC Audits with Trent Thiede](https://paasnational.com/podcast-a-deep-dive-into-ltc-audits-with-trent-thiede/): Trent Thiede, President of PAAS National and host of Amplify Long-Term Care Pharmacy Podcast, Frances Nahas talk all things pharmacy audits, from transitions of care to the complicated (and necessary) role PBMs play. Tune in to learn surprising insight of LTC audits to take your long-term care program to the next level.
- [Automatic Prescription Refill Concerns](https://paasnational.com/automatic-prescription-refill-concerns/): Many pharmacies use an automatic refill process to streamline the labor needed to fill prescriptions.
- [OMIG compliance reviews are happening now – this includes independent pharmacies!](https://paasnational.com/omig-compliance-reviews-are-happening-now-this-includes-independent-pharmacies/): PAAS National® has started to see New York State Office of the Medicaid Inspector General (OMIG) conducting reviews on pharmacies to evaluate if they have a compliance program that meets the new requirements of Social Services Law 363-d and 18 NYCRR Part 521.
- [PAAS Defends Community Pharmacies by Engaging DME Medicare Administrative Contractor CGS](https://paasnational.com/paas-defends-community-pharmacies-by-engaging-dme-medicare-administrative-contractor-cgs/): In our August Newsline Standard Written Order and Medicare Part B Audit Risks – New Guidance, we shared a few examples some of our members are having on audit results regarding their Standard Written Order (SWO). Beyond writing the Newsline, PAAS National® also reached out and engaged nurse medical reviewers with CGS about our concerns on the three topics below.
- [Best Practices for Billing Vaginal Creams to Avoid Recoupment](https://paasnational.com/best-practices-for-billing-vaginal-creams-to-avoid-recoupment/): PAAS National® analysts frequently receive questions regarding the proper billing of creams and ointments, an easy audit target for PBMs.
- [PAAS Pit Stop: On-Demand Webinars](https://paasnational.com/paas-pit-stop-on-demand-webinars/): Over the last three years, PAAS National’s President, Trent Thiede, has presented on-demand webinars, ranging from 15 to 45 minutes, to ensure our members gain the knowledge needed to avoid audits, stay abreast on the latest topics in the pharmacy world, and provide information on the more difficult topics in an easy-to-understand manner.
- [Ransomware Attacks – Is Your Data Protected?](https://paasnational.com/ransomware-attacks-is-your-data-protected/): Safeguarding electronic Protected Health Information (ePHI) is as important for a big Fortune 1000 company as it is for independent pharmacies.
- [NADAC Survey: What is It and Do I Need to Respond?](https://paasnational.com/nadac-survey-what-is-it-and-do-i-need-to-respond/): Pharmacies that receive a National Average Drug Acquisition Cost (NADAC) Survey frequently contact PAAS National® for information and guidance.
- [Caremark Invoice Audits – Pharmacy to Pharmacy Purchases](https://paasnational.com/caremark-invoice-audits-pharmacy-to-pharmacy-purchases/): PAAS National® continues to see PBM audits increase as we get further out from the formal end of the COVID-19 Public Health Emergency. One disturbing trend is the number of invoice audits, particularly from Caremark.
- [Are You Ready for Flu Shot Season? Auditors Are!](https://paasnational.com/are-you-ready-for-flu-shot-season-auditors-are/): It is that time of year again; flu shot season is upon us. As busy as this season can be, we know you do not want to worry if you have all the documentation you need in case of an audit.
- [Easy Audit Recoupment Prevention: Document Changes in Quantity Dispensed](https://paasnational.com/easy-audit-recoupment-prevention-document-changes-in-quantity-dispensed/): When you think about preventing recoupments, ensuring the correct NDC is billed, the prescription contains calculable directions, and proper DAW or days’ supply are common focuses; and rightfully so. However, there is another element to be aware of when filling prescriptions: documenting when the dispensed quantity is different than the quantity prescribed.
- [When Are Final Audit Results Not Final?](https://paasnational.com/when-are-final-audit-results-not-final/): Receiving audit results with discrepancies and financial recoupments can be very discouraging. PAAS National® analysts are here to assist you through the appeal process. Audit results do not always provide all appeal options, and you don’t want to miss out on another chance if your initial appeal is denied.
- [Recent DEA Rule Change - Partial Fills for Schedule II Controlled Substances](https://paasnational.com/recent-dea-rule-change-partial-fills-for-schedule-ii-controlled-substances/): The DEA recently updated the rule regarding partial fills of Schedule II (C-II) prescriptions. Pursuant to the Comprehensive Addiction and Recovery Act (CARA) of 2016, pharmacies are allowed to partial fill any C-II (e.g., stimulants, opioids, etc.) at the request of the prescriber, or the patient, as long as all the following criteria are met ...
- [Excluded Individual Creates Chaos for A Pharmacy IF Not Caught Right Away!](https://paasnational.com/excluded-individual-creates-chaos-for-a-pharmacy-if-not-caught-right-away/): Recently PAAS identified an excluded individual as an exact match through our proprietary exclusion checking offered by the Fraud, Waste & Abuse and HIPAA Compliance Program.
- [Migraine Medications Continue to Cause Headaches](https://paasnational.com/migraine-medications-continue-to-cause-headaches/): As PBMs continue to monitor claims for migraine medications, PAAS National® continues to receive questions about billing and the audit risks associated with these claims.
- [PAAS Pit Stop: The Member Portal](https://paasnational.com/paas-pit-stop-the-member-portal/): The PAAS Member Portal is a wealth of information and resources, whether you are part of the Audit Assistance and/or Fraud, Waste, & Abuse and HIPAA Compliance Program.
- [Caution with Script Care Audits](https://paasnational.com/caution-with-script-care-audits/): PAAS National has seen a rise in desk audits from Script Care.
- [Billing Test Claims? It Can Cost You!](https://paasnational.com/billing-test-claims-it-can-cost-you/): We have all been there - a prescriber calls the pharmacy to find out which prescription from a therapeutic category will be the most cost-effective for the patient.
- [Standard Written Order and Medicare Part B Audit Risks – New Guidance](https://paasnational.com/standard-written-order-and-medicare-part-b-audit-risks-new-guidance/): If you are a Medicare Part B provider, then you know how cumbersome a Medicare Part B audit can be. For most Medicare Part B audits, a pharmacy would be required to provide a valid Standard Written Order (SWO), medical records to support the diagnosis and continued need of the item, proof of delivery, and proof of refill request if mailing or delivering supplies.
- [Alleged Inattentiveness to Details Costs Pharmacy $70,000](https://paasnational.com/alleged-inattentiveness-to-details-costs-pharmacy-70000/): The DEA was established as a federal agency to regulate drug laws and to prevent misuse and/or diversion of both controlled substance and non-controlled medications.
- [Considerations With Ozempic 0.25 Weekly](https://paasnational.com/considerations-with-ozempic-0-25-weekly/): PAAS National analysts receive many questions on Ozempic® relating to concerns about off label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing.
- [Electronic Clinical Notes: Are They Required?](https://paasnational.com/electronic-clinical-notes-are-they-required/): There has been some discussion in pharmacy circles about clinical notes and whether PBMs are requiring them to be electronically annotated (or if hand-written clinical notes will continue to suffice).
- [Desk Audits for Worker’s Compensation Claims](https://paasnational.com/desk-audits-for-workers-compensation-claims/): PAAS National® analysts have recently seen an increase in desk audits for worker’s compensation claims, mostly performed by Script Care.
- [Auditors Crack Down on Pharmacies That Bypass Plan Limits](https://paasnational.com/auditors-crack-down-on-pharmacies-that-bypass-plan-limits/): PAAS National® analysts want to warn pharmacies about an uptick in PBMs flagging prescriptions for bypassing plan limit rejects.
- [Nearly 90% of Cyber Breaches are Caused by…](https://paasnational.com/nearly-90-of-cyber-breaches-are-caused-by/): Every day, pharmacies and their hardworking staff safeguard patients’ Protected Health Information (PHI), but breaches still occur.
- [MATE Training for Buprenorphine Prescribers](https://paasnational.com/mate-training-for-buprenorphine-prescribers/): Medication Access and Training Expansion (MATE) Act, requires all new or renewing DEA registrants to have met at least one of the following requirements when submitting their DEA registration application.
- [Seeing Too Many or Repeated Prescription Validation Requests – Take Action!](https://paasnational.com/seeing-too-many-or-repeated-prescription-validation-requests-take-action/): See the PAAS tips for best practices on how to track and manage duplicate or high numbers of prescription validation requests.
- [Invoice Audits Are on the Rise – Are You Prepared for Success?](https://paasnational.com/invoice-audits-are-on-the-rise-are-you-prepared-for-success/): Most pharmacies have grown accustomed to desk audits and providing copies of prescriptions, signature logs, and even copay collection records to PBMs upon request. Additionally, many pharmacies can recount their most recent experience with an onsite auditor visiting their pharmacy and the numerous questions related to operations, policies & procedures, and credentialing. However, not as many pharmacies have experienced an invoice audit – the stakes are higher and honest mistakes can lead to very expensive lessons in the process.
- [Are You Missing Audit Communications?](https://paasnational.com/are-you-missing-audit-communications/): PAAS National® analysts have recently seen many PBMs and audit contractors send communications, including audit letters, to network pharmacies via email instead of facsimile or postal mail.
- [Incorrect NDC or NPI Billed? Humana Requires Corrections](https://paasnational.com/incorrect-ndc-or-npi-billed-humana-requires-corrections/): Humana has recently sent out another round of audits where either an incorrect NDC number or National Provider Identifier (NPI) was billed.
- [At Your Own Risk: “Use as Directed”](https://paasnational.com/at-your-own-risk-use-as-directed/): How many times have you received a prescription for a bowel prep, starter pack, or pre-packaged taper where the directions simply state, “Use as Directed?”
- [HHS Reports Successes in Access to Meaningful Language Assistance Services](https://paasnational.com/hhs-reports-successes-in-access-to-meaningful-language-assistance-services/): For the first time since 2016, Health and Human Services (HHS) released a report detailing the progress made in improving “meaningful access to language assistance services” for individuals who are considered to have limited English proficiency (LEP).
- [Remember to Maintain and Provide Complete Clinical Notes!](https://paasnational.com/remember-to-maintain-and-provide-complete-clinical-notes/): Pharmacies must be very diligent with electronic documentation when electronically storing their prescriptions.
- [Dispense in Original Container - Know the Audit Risks](https://paasnational.com/dispense-in-original-container-know-the-audit-risks/): PAAS National® analysts want to remind pharmacies of the audit risks when medications are dispensed outside manufacturer storage/dispensing requirements.
- [PBM Communications to Network Pharmacies Can Help Prevent an Audit!](https://paasnational.com/pbm-communications-to-network-pharmacies-can-help-prevent-an-audit/): PAAS National® knows community pharmacies are busier than ever, making it difficult to keep up with all the PBM communications.
- [Social Media Mishap Leads to $30,000 Fine for Health Care Provider](https://paasnational.com/social-media-mishap-leads-to-30000-fine-for-health-care-provider/): Be very cautious about what information is posted on social media because one slip up could land your pharmacy in the crosshairs of an Office for Civil Rights (OCR) investigation.
- [NEW PAAS Tool Available – The Insulin Flow Chart You NEED to Download Today!](https://paasnational.com/new-paas-tool-available-the-insulin-flow-chart-you-need-to-download-today/): Our PAAS National® Analyst team is at it again! A new tool has been developed to address and correct a common audit recoupment issue. Insulin remains at the heart of nearly all audits.
- [Medication Error Reporting Through PAAS' FWA/HIPAA Compliance Program](https://paasnational.com/medication-error-reporting-through-paas-fwa-hipaa-compliance-program/): The importance of having an internal process to record and monitor medication errors cannot be overstated.
- [Humana Provides Update on GLP-1 Prescriptions](https://paasnational.com/humana-provides-update-on-glp-1-prescriptions/): PAAS National® has recently become aware of an update Humana published regarding new point-of-sale edits for specific medications.
- [Audit Risks with Schedule II Laddered Prescriptions](https://paasnational.com/audit-risks-with-schedule-ii-laddered-prescriptions/): Pharmacies receiving laddered Schedule II prescriptions must be aware of the DEA requirements and potential audit risks. Missing these requirements can lead to Federal law violations and PBM audit recoupment.
- [Appropriate Billing for CeQur SimplicityTM Patch and Insulin](https://paasnational.com/appropriate-billing-for-cequr-simplicitytm-patch-and-insulin/): Use the following information when billing CeQur Simplicity TM patches and the rapid-acting insulin used within the patch to decrease your risk of recoupment upon audit.
- [Billing Tips for Dexcom G6®](https://paasnational.com/billing-tips-for-dexcom-g6/): Dexcom G6® sensors, transmitters, and receivers continue to be audit targets.
- [Off-Label Use Beyond GLP-1](https://paasnational.com/off-label-use-beyond-glp-1/): GLP-1 medications being used off-label for weight loss, and the corresponding audit risk, has been a hot topic for awhile now, but there are other medications that PAAS National® frequently sees recoupments for when being used off-label, especially when billed to a Medicare plan.
- [Billing Guidance: When to Use DAW 0 vs DAW 9](https://paasnational.com/billing-guidance-when-to-use-daw-0-vs-daw-9/): PAAS National® analysts frequently see PBM audit results where auditors have flagged claims with ‘incorrect DAW code submitted’ – while these are often educational discrepancies, it is important to understand the implications of incorrect DAW code submission and develop a consistent process for pharmacy staff to follow.
- [On-Demand Webinar: Audit Preparation for the End of the Public Health Emergency](https://paasnational.com/on-demand-webinar-audit-preparation-for-the-end-of-the-public-health-emergency/): On May 4, 2023, PAAS National® hosted a webinar: Audit Preparation for the End of the Public Health Emergency. PAAS Audit Assistance members have access to the recorded webinar, in addition to many other tools and resources on the PAAS Member Portal.
- [Carry Clinical Notes Forward for Audit Coverage](https://paasnational.com/carry-clinical-notes-forward-for-audit-coverage/): Seasoned pharmacy staff can often list off the patients who prefer brand drug or whose insurance requires the brand name for certain medications.
- [Insurance Limits Quantity – Common Scenarios and Pitfalls](https://paasnational.com/insurance-limits-quantity-common-scenarios-and-pitfalls/): When processing prescriptions, insurance companies require pharmacies to bill an accurate days’ supply derived from mathematical calculations obtained from the directions.
- [LifeScan Extortion - Diabetic Test Strip “Authorized Distributors”](https://paasnational.com/lifescan-extortion-diabetic-test-strip-authorized-distributors/): For the second time in the last three years, numerous pharmacies have received, what PAAS National® would consider extortionary, letters from LifeScan.
- [Audit Target – Pre-Filled Injectable Pens and Syringes](https://paasnational.com/audit-target-pre-filled-injectable-pens-and-syringes/): Pre-filled injectable medication such as insulin, Invega®, Humira®, Enbrel® and Ozempic® remain a big target for audit risk due to their high cost and potential billing pitfalls.
- [Post-PHE Claim Submission Requirements for Continuous Glucose Monitors](https://paasnational.com/post-phe-claim-submission-requirements-for-continuous-glucose-monitors/): Now that the PHE has ended and CMS is enforcing clinical indications for CGMs and supplies, pharmacies are left wondering what will happen with continued or refilled claims for CGM related supply items initially provided during the PHE under the waiver/non-enforcement.
- [Resist the Urge: Don’t Reverse Claims After Receiving an Audit](https://paasnational.com/resist-the-urge-dont-reverse-claims-after-receiving-an-audit/): Consider the following situation: after pulling hard copy prescriptions for an audit, a billing error is identified; such as an incorrect days’ supply or billed quantity. The initial thought may be to reverse and rebill the claim.
- [Best Practices for Dispensing GLP-1 Medications and Reducing Recoupment Risk](https://paasnational.com/best-practices-for-dispensing-glp-1-medications-and-reducing-recoupment-risk/): Pharmacies continue to see a large number of prescriptions for GLP-1 medications like Ozempic and Mounjaro and have concerns about the risk of PBM audits and recoupments.
- [Quantity Changes Cause Audit Appeal Trouble](https://paasnational.com/quantity-changes-cause-audit-appeal-trouble/): PAAS National® is seeing more discrepancies for “unauthorized” refills on audits and PBMs continue to make these discrepancies difficult to appeal.
- [Insulin For a Pump: The Recoupment You Never Saw Coming](https://paasnational.com/insulin-for-a-pump-the-recoupment-you-never-saw-coming/): There are many billing pitfalls related to insulin claims, which is why auditors love to target them. The claim can face recoupment for a missing or incorrect strength, formulation, substitution, days’ supply calculation and so on, but one recoupment many pharmacies never see coming is insulin for a pump being inappropriately billed.
- [Ozempic® Package Size Change](https://paasnational.com/ozempic-package-size-change/): All strengths of Ozempic® now come in 3 mL pens. Pharmacies have frequently asked how this change affects patients’ current prescriptions.
- [Continuous Glucose Monitors and Potential Audit Risk with PHE Ending](https://paasnational.com/continuous-glucose-monitors-and-potential-audit-risk-with-phe-ending/): As the COVID-19 Public Health Emergency (PHE) declaration comes to an end on May 11, 2023, preparing for some changes to current flexibilities, actions and waivers that have been in place since COVID-19 began is crucial.
- [Caremark Memo: Novolog® and Novolin® ReliOn®](https://paasnational.com/caremark-memo-novolog-and-novolin-relion/): PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
- [PBMs on the Hot Seat in Key Legal and Administrative Battles](https://paasnational.com/pbms-on-the-hot-seat-in-key-legal-and-administrative-battles/): In a not-so-strange turn of events, pharmacy benefits managers (PBMs) are under scrutiny for alleged legal and administrative violations in states with robust PBM reform.
- [HIPAA Breach Notification Letter Sent to 82,466 Patients Due to Improperly Shared Data](https://paasnational.com/hipaa-breach-notification-letter-sent-to-82466-patients-due-to-improperly-shared-data/): According to the U.S. Department of Health and Human Services breach portal, the mail-order pharmacy Healthy Options dba Kroger Postal Prescription Services (PPS) reported a breach of information which affected 82,466 patients.
- [Nuances of Insulin Pens and How They May Differ](https://paasnational.com/nuances-of-insulin-pens-and-how-they-may-differ/): Priming insulin pens prior to use helps ensure the appropriate dose is being administered.
- [Avoiding Humana Audits for Deceased Patients](https://paasnational.com/avoiding-humana-audits-for-deceased-patients/): Humana has recently sent out another round of audits to pharmacies with the subject line: Review of claim(s) billed after member’s deceased date.
- [LifeScan Continues to Pursue Pharmacies Purchasing from Unauthorized Distributors](https://paasnational.com/lifescan-continues-to-pursue-pharmacies-purchasing-from-unauthorized-distributors/): PAAS National® has assisted on numerous cases pertaining to test strip manufacturers (and PBMs) trying to recoup funds on the premise of pharmacies utilizing unauthorized distributors.
- [LIVE WEBINAR MAY 4th: Audit Preparation for the End of the Public Health Emergency](https://paasnational.com/live-webinar-may-4th-audit-preparation-for-the-end-of-the-public-health-emergency/): Join President of PAAS National®, Trenton Thiede, PharmD, MBA for a LIVE webinar “Audit Preparation for the End of the Public Health Emergency ” on May 4, 2023 from 2-2:45pm CT
- [Biologic Drug Substitution Best Practices (Update)](https://paasnational.com/biologic-drug-substitution-best-practices-update/): PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
- [Caremark Resumes Signature Log Requirements Effective May 12, 2023](https://paasnational.com/caremark-resumes-signature-log-requirements-effective-may-12-2023/): Caremark issued a Pharmacy Update memo on March 8, 2023, stating that they would resume signature log requirements for audits effective May 12, 2023.
- [PerformRx<sup>SM</sup> Investigational Audits Are on the Rise](https://paasnational.com/performrxsm-investigational-audits-are-on-the-rise/): PAAS National® has recently seen a new trend with investigational audits completed by PerformRxSM. These audits are a combination of an invoice, desk, and a compliance audit.
- [Best Practices: Medication Delivery](https://paasnational.com/best-practices-medication-delivery/): With the Public Health Emergency (PHE) for COVID-19 ending May 11, 2023, a return to pre-pandemic requirements for proving patient receipt of medications is anticipated.
- [Prepare Yourselves! Onsite Audits Are Coming in Strong](https://paasnational.com/prepare-yourselves-onsite-audits-are-coming-in-strong/): Health and Human Services (HHS) is planning for the public health emergency (PHE) to expire on May 11, 2023 and PBM auditors are in full swing of resuming their onsite visits. Onsite audits have always been the most aggressive and highest risk to community pharmacies.
- [A Documentation Checklist for Continuous Glucose Monitor Claims](https://paasnational.com/a-documentation-checklist-for-continuous-glucose-monitor-claims/): For any item to be covered by Medicare B, there must be clinical documentation to support the covered diagnosis, prove it is reasonable and necessary for treatment and meet all other Medicare requirements.
- [Express Scripts Provider Manual – 2023 Updates](https://paasnational.com/express-scripts-provider-manual-2023-updates/): All PBMs update their Provider Manuals at regular intervals and Express Scripts (ESI) is no exception.
- [Black Market HIV Medications Are Not Worth the Savings!](https://paasnational.com/black-market-hiv-medications-are-not-worth-the-savings/): According to a statement released by the U.S Attorney’s Office in the Southern District of New York, five individuals were arrested the morning of March 2, 2023 as a result of defrauding government insurance plans, including Medicaid and manipulating low-income individuals out of their HIV medications from July 2020 through February 2023.
- [<strong>Biosimilar Adoption for Humira in 2023</strong>](https://paasnational.com/biosimilar-adoption-for-humira-in-2023/): While Semglee® was the first interchangeable biosimilar to market back in 2021, Humira has been grabbing attention because of its status as the pharma-GOAT: Greatest Of All Time (in terms of sales) as coined by Doug Hoey from NCPA.
- [Be On the Lookout for Prescription Reversal Requests from Humana](https://paasnational.com/be-on-the-lookout-for-prescription-reversal-requests-from-humana/): Humana periodically performs retrospective claim reviews. If upon review Humana determines a claim was billed in error (i.e., after the Humana coverage was terminated), the pharmacy will get a prescription reversal letter.
- [Nuedexta<sup>®</sup> National Audit: A Tale of Medically Accepted Indications](https://paasnational.com/nuedexta-national-audit-a-tale-of-medically-accepted-indications/): PAAS National® stresses the importance of medications being prescribed for a medically accepted indication (MAI), particularly for Medicare, Medicaid and Tricare, as this carries an audit risk that is difficult to overturn on appeal.
- [Discount/Cash Cards Are Disruptors in the Industry](https://paasnational.com/discount-cash-cards-are-disruptors-in-the-industry/): On February 25, 2023, President of PAAS National®, Trent Thiede, had the privilege of participating in a Panel Discussion entitled Marketplace Prescription Dynamics Sure to Shape Your Business Strategies. While traversing several different topic areas, there are two core issues that are important for PAAS members: discount/cash cards and biosimilar adoption in 2023.
- [Proof of Copay Collection - Secondary Payers Hidden in Plain Sight](https://paasnational.com/proof-of-copay-collection-secondary-payers-hidden-in-plain-sight/): If your pharmacy has not had to deal with proof of copay collection on an audit, your time is coming.
- [Not-So-GoodRx Reprimanded $1.5 million for Sharing Consumers’ Information](https://paasnational.com/not-so-goodrx-reprimanded-1-5-million-for-sharing-consumers-information/): The article GoodRx Shares Consumer Data appeared in the April 2020 Newsline, which pertained to GoodRx sharing their consumers’ data with various platforms, including Facebook and Google.
- [LTC Is Different … Do Auditors Agree?](https://paasnational.com/ltc-is-different-do-auditors-agree/): PAAS National® analysts frequently assist pharmacies that service LTC facilities. Three audit flags PAAS analysts frequently see for LTC pharmacies
- [Proper Billing for Intermittent Use Medications](https://paasnational.com/proper-billing-for-intermittent-use-medications/): Calculating proper days’ supply on continuous use medications can be hard enough; how do PBMs and auditors view medications that are used intermittently?
- [Audit Trap: OptumRx’s Provider Manual Requirements](https://paasnational.com/audit-trap-optumrxs-provider-manual-requirements/): PAAS National® is starting to see more recoupments from OptumRx for missing prescription information.
- [PHE for COVID-19 Ending May 11, 2023: Pharmacy and Audit Ramifications](https://paasnational.com/phe-for-covid-19-ending-may-11-2023-pharmacy-and-audit-ramifications/): On January 30, 2023, President Biden’s administration announced that both the national emergency and public health emergency (PHE) for COVID-19 would be ending on May 11, 2023. This will have far-reaching implications for everyone in healthcare, including pharmacy.
- [Levemir<sup>®</sup> FlexPen<sup>®</sup> is Replacing the Levemir<sup>®</sup> FlexTouch<sup>®</sup>](https://paasnational.com/levemir-flexpen-is-replacing-the-levemir-flextouch/): Novo Nordisk® discontinued manufacturing the Levemir® FlexTouch® in early February 2023.
- [To Sign, or Not to Sign, the OptumRx<sup>®</sup> Recoupment Waiver ... That Is the Question](https://paasnational.com/to-sign-or-not-to-sign-the-optumrx-recoupment-waiver-that-is-the-question/): If your pharmacy has recently been through an OptumRx® desk audit, you may have come across the OptumRx Provider Intent Form – Recoupment Waiver.
- [First Step in Getting Help with an Audit](https://paasnational.com/first-step-in-getting-help-with-an-audit/): Oh no! You just received an audit, now what? Your first step is to get the audit notice to PAAS National.
- [Ozempic and Mounjaro Prescriptions – Between a Rock and a Hard Place](https://paasnational.com/ozempic-and-mounjarotm-prescriptions-between-a-rock-and-a-hard-place/): Many pharmacies continue to receive new prescriptions from patients eager to start on therapy for Ozempic and Mounjaro.
- [Are Your Delivery/Signature Logs PBM Compliant for 2023?](https://paasnational.com/are-your-delivery-signature-logs-pbm-compliant-for-2023/): A common component of a pharmacy audit request is the delivery/signature log.
- [Process for Dealing with a Patient HIPAA Complaint](https://paasnational.com/process-for-dealing-with-a-patient-hipaa-complaint/): Anyone can file a complaint if they feel their rights under the HIPAA Privacy, Security, or Breach Rules have been violated.
- [Express Scripts Validating 340B Claim Eligibility](https://paasnational.com/express-scripts-validating-340b-claim-eligibility/): PAAS continues to see members receiving emails from Express Scripts (ESI) requesting pharmacies to ...
- [Update to PAAS’ Onsite Credentialing Guidelines](https://paasnational.com/update-to-paas-onsite-credentialing-guidelines/): PAAS National® has created an Onsite Credentialing Guidelines, an extensive checklist to assist PAAS members with scheduled and/or unexpected visits from PBM auditors. Unannounced visits can catch pharmacy staff off guard when the Pharmacist-in-Charge (PIC) is not present.
- [Multi-Language Insert Must Be Provided to Medicare Beneficiaries as of January 1, 2023](https://paasnational.com/multi-language-insert-must-be-provided-to-medicare-beneficiaries-as-of-january-1-2023/): After reading this article you should understand what a multi-language insert is, why it must be provided, and when you are required to hand it out.
- [Audit Risk: Pre-Printed Prescription Forms](https://paasnational.com/audit-risk-pre-printed-prescription-forms/): At a time when the workday seems to be growing ever more hectic, prescribers and pharmacies may find pre-printed prescription forms convenient; especially for medications which are frequently utilized by a prescriber for treatment. Many PBMs prohibit pre-printed prescription form use for various reasons.
- [Why Does Billing the Correct Origin Code Matter?](https://paasnational.com/why-does-billing-the-correct-origin-code-matter/): Pharmacies are required to enter an origin code on claims to indicate where the prescription came from or “originated.”
- [Medicare Caps Copay for Insulin at $35 per Month](https://paasnational.com/medicare-caps-copay-for-insulin-at-35-per-month/): As most of you (and your Medicare patients) have undoubtedly noticed, Medicare has applied a $35 per month cap on copays for insulin prescriptions ($105 for a 3-month supply) for years 2023-2025.
- [XDEA Numbers Have Been NiXed…but Not the Training](https://paasnational.com/xdea-numbers-have-been-nixedbut-not-the-training/): When you are preparing for an audit, a PAAS National® analyst has likely told you to ensure a prescriber’s Drug Addiction Treatment Act (DATA) 2000 Waiver ID, or XDEA number, is included on prescriptions for medications used to treat opioid use disorder along with their regular DEA number.
- [PBM Prescription Validation Requests Rose Nearly 20% in 2022!](https://paasnational.com/pbm-prescription-validation-requests-rose-nearly-20-in-2022/): Prescription Validation Requests (also known as claim reviews) are becoming a more frequent occurrence with many PBMs. In 2022, PAAS saw an 18% increase year over year. Some of the reasons these claims get flagged include...
- [Beware: Caremark is Monitoring High Quantity Utilization and Atypical Dispensing Habits](https://paasnational.com/beware-caremark-is-monitoring-high-quantity-utilization-and-atypical-dispensing-habits/): Beyond traditional desktop, on-site, investigational or invoice audits, Caremark performs various compliance reviews.
- [Top 10 PAAS National Articles of 2022](https://paasnational.com/top-10-paas-national-articles-of-2022/): PAAS Audit Assistance members receive a monthly newsletter with new audit tactics and prevention tips.
- [Criminal HIPAA Charges Filed Against Compounding Pharmacy Sales Rep](https://paasnational.com/criminal-hipaa-charges-filed-against-compounding-pharmacy-sales-rep/): Criminal HIPAA charges are not handed down frequently, but when an individual “knowingly” and inappropriately obtains and discloses a patient’s protected health information (PHI), they could face up to $50,000 in fines and up to one year in prison.
- [Valid Prescriber/Patient Relationships and Marketing Concerns](https://paasnational.com/valid-prescriber-patient-relationships-and-marketing-concerns/): With the U.S. Department of Health and Human Services Office of Inspector General’s (OIG) recent focus on telemedicine fraud, pharmacies may be wondering what their obligations are when determining a prescription’s authenticity - especially when it comes to whether a valid prescriber/patient relationship exists.
- [2023 Fraud, Waste & Abuse and HIPAA Compliance Program Updates](https://paasnational.com/2023-fraud-waste-abuse-and-hipaa-compliance-program-updates/): The PAAS National® FWA/HIPAA Compliance Program has implemented changes to ensure pharmacies continue to have a robust program in place.
- [2022 CVS Caremark Provider Manual Supplement for 2023](https://paasnational.com/2022-cvs-caremark-provider-manual-supplement-for-2023/): Caremark has released the 2022 CVS Caremark Provider Manual Supplement which is effective January 1, 2023.
- [Natesto<sup>®</sup> Nasal Gel Pump – Bill It Right!](https://paasnational.com/natesto-nasal-gel-pump-bill-it-right/): Pharmacies have begun to see more prescriptions for Natesto® (testosterone) nasal gel.
- [Start of New Year = Opioid Plan Rejects](https://paasnational.com/start-of-new-year-opioid-plan-rejects/): PAAS National® analysts receive numerous calls at the start of the new year looking for guidance on opioid plan rejects.
- [Update: Medicare Part D Mandatory E-Prescribing Requirements for Controlled Substances - Final Rule](https://paasnational.com/update-medicare-part-d-mandatory-e-prescribing-requirements-for-controlled-substances-final-rule/): PAAS National® alerted pharmacies to the delay in enforcement of Electronic Prescribing for Controlled Substances (EPCS) for Medicare Part D until January 1, 2023.
- [FDA’s Guidance on Compounding Commercially Available Products in Short Supply](https://paasnational.com/fdas-guidance-on-compounding-commercially-available-products-in-short-supply/): For various reasons, including ingredient shortages or manufacturer back orders, a pharmacist may be required to compound a commercially available product.
- [New Tool on PAAS Portal - DMEPOS Article Series 2022](https://paasnational.com/new-tool-on-paas-portal-dmepos-article-series-2022/): PAAS National® wrote a DMEPOS article series in 2022, which includes 8 articles to be proactive in preventing audits.
- [Prescriber Statement Requirements Needed for Prescription Discrepancies](https://paasnational.com/prescriber-statement-requirements-needed-for-prescription-discrepancies/): Appealing audit discrepancies can be confusing and time consuming. PAAS National® analysts have over 50 years of dedicated audit assistance experience, and review nearly 10,000 audits a year.
- [The Ballad of Snowbirds and Audits](https://paasnational.com/the-ballad-of-snowbirds-and-audits/): The winter months have many pharmacies mailing prescriptions to their snowbird patients who leave their northern nests for more hospitable climates.
- [Essential Elements of Corrective Action Plans](https://paasnational.com/essential-elements-of-corrective-action-plans/): PAAS National® analysts have recently seen an increased number of PBM audits with “significant” results, including a large number of unique issues, large dollar amounts (>$100,000) or both. Audits of this magnitude may trigger further consequences such as additional audits, payment suspension and/or threat of network termination.
- [Navigating PBM Audits](https://paasnational.com/navigating-pbm-audits/): Working collaboratively can be key to either avoiding a PBM audit altogether or making the process as painless as possible.
- [On-Demand Webinar: Don’t Give PBMs a Reason to Audit (Or Terminate): Off-Label Drug Use and Compliance Requirements](https://paasnational.com/on-demand-webinar-dont-give-pbms-a-reason-to-audit-or-terminate-off-label-drug-use-and-compliance-requirements/): On November 9, 2022 PAAS National® hosted “Don’t give PBMs a reason to audit (or terminate): Off-label drug use and compliance requirements” webinar.
- [Medicare Extends Part B Coverage for Kidney Transplant Drugs](https://paasnational.com/medicare-extends-part-b-coverage-for-kidney-transplant-drugs/): Patients with Medicare because of End-Stage Renal Disease (ESRD) currently lose coverage 36 months after a kidney transplant unless otherwise eligible for Medicare.
- [Beware of the New Problem with the Updated Online Santyl<sup>®</sup> Calculator](https://paasnational.com/beware-of-the-new-problem-with-the-updated-online-santyl-calculator/): Santyl® ointment 250 units/gram is a topical medication indicated for debriding chronic dermal ulcers and severely burned areas.
- [Express Scripts Reminds Pharmacies of Copay Collection Obligations](https://paasnational.com/express-scripts-reminds-pharmacies-of-copay-collection-obligations/): Express Scripts sent a memo to network providers the middle of October, pertaining to copayment collection, to ensure requirements are being met in the appropriate manner.
- [What Do Bowel Preps, EpiPen<sup>®</sup>, and Migraine Medications Have in Common?](https://paasnational.com/what-do-bowel-preps-epipen-and-migraine-medications-have-in-common/): Prescriptions for medications whose dosing is standardized in the industry often come with directions that simply state, “Use as directed.”
- [Pharmacy to Pharmacy Inventory Transfers – Buyer Beware!](https://paasnational.com/pharmacy-to-pharmacy-inventory-transfers-buyer-beware/): Pharmacy to pharmacy transfers are commonplace in the industry, but much has changed since Lipitor® and Prevacid® were used as currency in a legal drug exchange.
- [DMEPOS Mini-Series #8 – The Six Medicare Auditing Entities and Their Purpose](https://paasnational.com/dmepos-mini-series-8-the-six-medicare-auditing-entities-and-their-purpose/): The six Medicare auditing entities are responsible for auditing records, claims and payments. What is the rationale for having these auditing entities?
- [Be on the Lookout for OptumRx Unannounced Onsite Audits](https://paasnational.com/be-on-the-lookout-for-optumrx-unannounced-onsite-audits/): Being prepared for an unannounced audit is crucial and PAAS National® wants to make sure you have the tools to be successful.
- [Caremark Bulk Purchase Requirements](https://paasnational.com/caremark-bulk-purchase-requirements/): As 2022 comes to a close, we know that many pharmacies will make “bulk purchases” ahead of the new year in anticipation of price increases or to obtain wholesaler rebates.
- [Authorized Distributors of OTC Diabetic Test Devices](https://paasnational.com/authorized-distributors-of-otc-diabetic-test-devices/): Most pharmacies are familiar with the basic requirements of the Drug Supply Chain Security Act (DSCSA), including the requirement to purchase prescription products from authorized suppliers.
- [Tips for Tackling PBM Audits—Together](https://paasnational.com/tips-for-tackling-pbm-audits-together/): Curious why audits happen? It’s as simple as rising health care costs and improvements in data analytics that find outliers more easily.
- [Product Substitution Best Practices](https://paasnational.com/product-substitution-best-practices/): Consider a scenario where your pharmacy has been dispensing a product for years and you find that the product is being discontinued, requiring a product substitution.
- [NCPDP Modified Section 11.15 of the Emergency Preparedness Guidance Document – COVID-19 Oral Antivirals Billing](https://paasnational.com/ncpdp-modified-section-11-15-of-the-emergency-preparedness-guidance-document-covid-19-oral-antivirals-billing/): PAAS would like to point out some of the updates and additions to section 11.15 of the document Billing of a Self-Administered Free COVID-19 Oral Antiviral During an Emergency.
- [Mounjaro<sup>TM</sup> Off-Label Use for Weight Loss Spells T-R-O-U-B-L-E](https://paasnational.com/mounjarotm-off-label-use-for-weight-loss-spells-t-r-o-u-b-l-e/): PAAS National® analysts have received many phone calls regarding prescriptions for MounjaroTM – in most cases the medication is suspected of being used “off-label” for weight loss.
- [Akorn Agrees to Pay Nearly $8 Million to Settle False Claims Allegations](https://paasnational.com/akorn-agrees-to-pay-nearly-8-million-to-settle-false-claims-allegations/): Akorn Operating Company LLC (Akorn) has agreed to pay $7.9 million for allegedly violating the False Claims Act causing Medicare to pay for invalid prescription drugs according to a recent Department of Justice press release.
- [Missing DUR and SCC Documentation Can Lead to Recoupment!](https://paasnational.com/missing-dur-and-scc-documentation-can-lead-to-recoupment/): Many pharmacy teams are overwhelmed with the increasing daily workload. This can result in data entry staff creating shortcuts, like entering override codes to get claims processed.
- [OIG Telehealth Fraud Concerns](https://paasnational.com/oig-telehealth-fraud-concerns/): In September 2022, the U.S. Department of Health and Human Services Office of Inspector General (OIG) put out a report on program integrity risks concerning Medicare telehealth services during the first year of the COVID-19 pandemic.
- [DMEPOS Mini-Series #7 – Immunosuppressive Drugs for Transplant](https://paasnational.com/dmepos-mini-series-7-immunosuppressive-drugs-for-transplant/): This month, we continue with our DMEPOS mini-series by discussing yet another challenging category - immunosuppressive drugs for a transplant. Immunosuppressive drugs are only covered under Part B to maintain an organ transplant that was Medicare eligible.
- [Yes, LTC Delivery Manifests ARE Needed!](https://paasnational.com/yes-ltc-delivery-manifests-are-needed/): PAAS National® analysts often see LTC pharmacies struggle with providing sufficient documentation to satisfy proof of dispensing for an audit.
- [Does My Pharmacy Really Need Cultural Competency Training?](https://paasnational.com/does-my-pharmacy-really-need-cultural-competency-training/): As a reminder, pharmacies are now required, as part of their NCPDP profile, to address if the pharmacy maintains evidence of cultural competency training.
- [LIVE WEBINAR NOVEMBER 9th - Sign Up Today!](https://paasnational.com/live-webinar-november-9th-dont-give-pbms-a-reason-to-audit-or-terminate-off-label-drug-use-and-compliance-requirements/): Join President of PAAS National®, Trenton Thiede, PharmD, MBA for a LIVE webinar “Don’t give PBMs a reason to audit (or terminate): Off-label drug use and compliance requirements” on November 9, 2022 from 2:00-3:00 pm CT.
- [“Unauthorized Refills” Audit Discrepancies; How Does This Happen?](https://paasnational.com/unauthorized-refills-audit-discrepancies-how-does-this-happen/): Audit results flagging “unauthorized refills” or “overbilled quantity,” can lead to big recoupments.
- [Three Common Pitfalls to Avoid When Billing Oral Inhalers](https://paasnational.com/three-common-pitfalls-to-avoid-when-billing-oral-inhalers/): Oral inhalers remain a high audit risk for all PBMs and being able to identify billing pitfalls may mean the difference between a claim safe from recoupment and one lost due to an improper DAW code, early refill, or overbilled quantity.
- [Are You Prepared for an OTC COVID-19 Test Audit?](https://paasnational.com/are-you-prepared-for-an-otc-covid-19-test-audit/): Billing and dispensing OTC COVID-19 tests is widespread throughout community pharmacies.
- [<strong>Flu Shot Season Is Here - What Is Needed for Audit?</strong>](https://paasnational.com/flu-shot-season-is-here-what-is-needed-for-audit/): COVID-19 has forced a significant increase in the number of vaccinations pharmacies do daily. With this increase also comes additional audits.
- [How Can I Avoid Humana Audits for Deceased Patients?](https://paasnational.com/how-can-i-avoid-humana-audits-for-deceased-patients/): Humana has recently sent out audits to pharmacies with a subject line stating Review of claim(s) billed after member’s deceased date.
- [Caremark Cease and Desist Letters – Trudhesa<sup>®</sup>](https://paasnational.com/caremark-cease-and-desist-letters-trudhesa/): PAAS National® analysts have recently assisted a few pharmacies that received “Cease and Desist” Letters from Caremark related to dispensing Trudhesa® nasal spray for migraines.
- [Are You Utilizing DAW Codes Correctly? Updated Tool Available!](https://paasnational.com/are-you-utilizing-daw-codes-correctly-updated-tool-available/): Though the definitions were revised to include biologic drug products, the guidance holds true for all legend drugs. Now is the time to refamiliarize yourself with the best-practices for using DAW codes and to review DAW code audit pitfalls most seen by PAAS National® analysts.
- [DMEPOS Mini-Series #6 – Therapeutic Shoes for Diabetes](https://paasnational.com/dmepos-mini-series-6-therapeutic-shoes-for-diabetes/): Every 17 seconds someone is diagnosed. Noridian, Jurisdiction D, has been conducting Targeted Probe and Educate reviews of HCPCS code A5500, which is for therapeutic shoes.
- [Bill It Right – Diazepam Gel](https://paasnational.com/bill-it-right-diazepam-gel/): Diazepam rectal gel continues to confuse prescribers and pharmacies alike when it comes to how a prescription is written and then ultimately filled and billed.
- [2022 DEA Pharmacist’s Manual Updates – What’s Changed?](https://paasnational.com/2022-dea-pharmacists-manual-updates-whats-changed/)
- [Breaking Insulin Pen Boxes: Where Are We Now?](https://paasnational.com/breaking-insulin-pen-boxes-where-are-we-now/): This month marks two years since the U.S. Food and Drug Administration (FDA) clarified their intentions behind revising insulin pen labeling, yet insulin pen boxes continue to present issues to pharmacies trying to establish best practices surrounding its dispensing and billing.
- [Proposed Section 1557 Rule – How Could It Affect You?](https://paasnational.com/proposed-section-1557-rule-how-could-it-affect-you/): The U.S. Department of Health and Human Services (HHS) has proposed to strengthen the interpretation of the Section 1557 of the Affordable Care Act (ACA)
- [Use and Posting of Guidance Documents by DEA – What’s Changed with Controlled Substance Annotations?](https://paasnational.com/use-and-posting-of-guidance-documents-by-dea-whats-changed-with-controlled-substance-annotations/): On June 23, 2022 the Drug Enforcement Agency (DEA) created a Guidance Document about the use and posting of guidance documents by the DEA (yes, a guidance document about guidance documents).
- [Prescription Quantity Changes Require Documentation](https://paasnational.com/prescription-quantity-changes-require-documentation/): Anytime you dispense a quantity different from what was prescribed, you should note why.
- [Combivent<sup>®</sup> Respimat<sup>®</sup> Still Causing Confusion](https://paasnational.com/combivent-respimat-still-causing-confusion/): The new inhaler was not an exact replacement of the old one. What happens if the plan will not allow a 20-day supply?
- [DMEPOS Mini-Series #5 – Surgical Dressings](https://paasnational.com/dmepos-mini-series-5-surgical-dressings/): Use these helpful tips and links to be prepared in case of an audit on surgical dressings.
- [Trudhesa™ Nasal Spray for the Treatment of Migraines](https://paasnational.com/trudhesa-nasal-spray-for-the-treatment-of-migraines/): Migraine relief medications are frequently monitored and flagged for audit due to high cost, quantities submitted, days’ supply and/or frequency of refills.
- [NCPDP Updates DAW Code Definitions to Encompass Interchangeable Biosimilars](https://paasnational.com/ncpdp-updates-daw-code-definitions-to-encompass-interchangeable-biosimilars/): While this chart is useful, you may be asking yourself – What does this all mean?! Let us go through several examples.
- [Medicare Part D Long-Term Institutionalized (LTI) Resident Report](https://paasnational.com/medicare-part-d-long-term-institutionalized-lti-resident-report/): PAAS National® recently assisted numerous pharmacies that received an email communication from Express Scripts stating the pharmacy had inappropriately billed Part D claims while patients were in a qualified Part A stay.
- [Automatic Mailing for Part D Patients](https://paasnational.com/automatic-mailing-for-part-d-patients/): Reminder tp pharmacies on some specific requirements when automatically mailing refills to Medicare Part D patients.
- [Navigating Rights & Responsibilities in a Post-Roe v. Wade World](https://paasnational.com/navigating-rights-responsibilities-in-a-post-roe-v-wade-world/): With the overturning of Roe v. Wade, the U.S. Supreme Court ruling on an individual’s rights surrounding abortion, pharmacies may be left wondering how to proceed.
- [Be Prepared for Audits on Pharmacist-Prescribed Paxlovid](https://paasnational.com/be-prepared-for-audits-on-pharmacist-prescribed-paxlovidtm/): As pharmacies across the country are gaining access to this anti-viral COVID-19 therapeutic agent, it is important to understand the specifications of the EUA..
- [DMEPOS Targeted Probe and Educate Program – Process Improvement Plan](https://paasnational.com/dmepos-targeted-probe-and-educate-program-process-improvement-plan/): There has been a sharp increase in the number of TEP audits on diabetic testing supplies, view commonly flagged deficiency categories.
- [LIVE WEBINAR AUGUST 17th: Understanding Interchangeability with Prescription Biologics](https://paasnational.com/live-webinar-august-17th-understanding-interchangeability-with-prescription-biologics/): Join President of PAAS National, Trenton Thiede, PharmD, MBA as he discusses understanding interchangeability with prescription biologics during a Live Webinar.
- [Be Audit Ready! Clinical Notes and Annotations: What Documentation is Essential for Audit?](https://paasnational.com/be-audit-ready-clinical-notes-and-annotations-what-documentation-is-essential-for-audit/): Make sure you have good documentation of the conversation with the prescriber’s office to successfully pass an audit that may occur years later.
- [DMEPOS Mini-Series #4 – Urological Supplies: Intermittent Catheters](https://paasnational.com/dmepos-mini-series-4-urological-supplies-intermittent-catheters/): If you are a Medicare Part B supplier, then you are aware that billing Medicare B is quite different than billing other payors.
- [Metformin ER – Can I Substitute?](https://paasnational.com/metformin-er-can-i-substitute/): Many pharmacies struggle with identifying which metformin ER product they can dispense or substitute, explore the three different strengths ...
- [Could You Be Giving Vaginal Creams Away for Free?](https://paasnational.com/could-you-be-giving-vaginal-creams-away-for-free/): PAAS National® analysts continue to see claims for Premarin® and Estrace® creams being audited and recouped. Are you in jeopardy?
- [Medication Synchronization: Possible Concerns](https://paasnational.com/medication-synchronization-possible-concerns/): See the tips below to ensure that your medication synchronization program will stand up to PBM scrutiny and keep you out of harm’s way.
- [LIVE WEBINAR JUNE 15th: Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency](https://paasnational.com/live-webinar-june-15th-caremarks-bulk-purchasing-requirements-and-the-importance-of-cultural-competency/): Join President of PAAS National®, Trenton Thiede for a LIVE webinar “Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency”
- [DMEPOS Mini-Series #3 – Diabetic Test Strips](https://paasnational.com/dmepos-mini-series-3-diabetic-test-strips/): If you are a Medicare Part B supplier, then you have likely had an audit on diabetic test strips. Billing Medicare Part B is quite different than other payors, and consequently, can be very challenging for pharmacies.
- [On-Demand Webinar: Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency](https://paasnational.com/on-demand-webinar-caremarks-bulk-purchasing-requirements-and-the-importance-of-cultural-competency/)
- [New Tools Available! Biologic and Non-Biologic Injectable Medication Reference Charts](https://paasnational.com/new-tools-available-biologic-and-non-biologic-injectable-medication-reference-charts/): Ever wonder if you were billing the correct NDC for a Humira® prescription and had to spend precious time investigating? Or how about questioning if you were billing the correct package size for Gvoke® and had to consult multiple references just to try and figure out the answer?
- [A Need for a Compliance Program – Attest with Confidence](https://paasnational.com/a-need-for-a-compliance-program-attest-with-confidence/): Since 2009, PAAS National® Fraud, Waste & Abuse and HIPAA Compliance program was designed to meet the CMS requirements, with the full support of our expert staff – pharmacists and technicians just like you, with years of experience helping community pharmacies with FWA and HIPAA compliance. Don’t be fooled by offers for training and exclusion checks – work with the best compliance program available to community pharmacies!
- [Insulin Glargine (Winthrop) – Unbranded Biologic of Lantus<sup>®</sup>](https://paasnational.com/insulin-glargine-winthrop-unbranded-biologic-of-lantus/): Insulin glargine labeled by Winthrop U.S. came to market in May 2022, and with it a lot of additional confusion regarding pharmacy level substitution.
- [Is Your Pharmacy Ready for an Unannounced Audit?](https://paasnational.com/is-your-pharmacy-ready-for-an-unannounced-audit/): Pharmacies are often startled with the limited amount of time a PBM offers prior to an onsite audit. However, PBM auditors, DEA agents, FDA inspectors and state Board of Pharmacy inspectors can also make unannounced visits.
- [Beware: DEA and Wholesalers are Cracking Down on Controlled Substance Dispensing](https://paasnational.com/beware-dea-and-wholesalers-are-cracking-down-on-controlled-substance-dispensing/): Take note – the DEA is coming after pharmacies dispensing illegitimate controlled substance prescriptions. Pharmacists should all be aware of their corresponding responsibility and the need for a legitimate medical purpose when dispensing controlled substance prescriptions.
- [When Should I Obtain a Diagnosis Code for Ozempic?](https://paasnational.com/when-should-i-obtain-a-diagnosis-code-for-ozempic/): Since Ozempic® was FDA approved December 5, 2017, PAAS National® has fielded many questions regarding dispensing this expensive injectable diabetic medication.
- [Why PAAS Cultural Competency?](https://paasnational.com/why-paas-cultural-competency/): Developed by pharmacists for community pharmacies, PAAS National® brings you a tailored approach to Cultural Competency and Linguistically Appropriate Services using the PAAS Care Model.
- [Hope to See You In-Person at an Upcoming Event!](https://paasnational.com/hope-to-see-you-in-person-at-an-upcoming-event/): PAAS National® will be at the following upcoming events and we hope to see you in-person.
- [A Lifeline for Pharmacy Audits](https://paasnational.com/a-lifeline-for-pharmacy-audits/): Join Trent Thiede, President of PAAS National in the most recent podcast "A Lifeline for Pharmacy Audits", hosted by Jeff Key, President of PioneerRx and Marsha Bivins, Director of Marketing of PioneerRx
- [Beyond-Use Date vs. Nursing Home Storage Policy – Avoid this Recoupment Trap!](https://paasnational.com/beyond-use-date-vs-nursing-home-storage-policy-avoid-this-recoupment-trap/): Manufacturers go through rigorous testing to bring their products to market and part of the tedious approval process includes stability, sterility, and beyond-use date (BUD) testing.
- [DMEPOS Mini-Series #2 – Ostomy Supplies](https://paasnational.com/dmepos-mini-series-2-ostomy-supplies/): PAAS National® often sees recoupments on ostomy supplies due to unsupported medical records.
- [Announcing Premier Cultural Competency Training by PAAS National](https://paasnational.com/announcing-premier-cultural-competency-training-by-paas-national/): Beyond PBM requirements and NCPDP attestations, pharmacies need to provide services to all patients in a culturally competent manner - free of discrimination.
- [Understanding Caremark’s Restrictions on Bulk Purchases](https://paasnational.com/understanding-caremarks-restrictions-on-bulk-purchases/): Community pharmacies have been fed up with PBM antics for a long time. Egregious audits, absurd DIR fees, arduous credentialing requirements, unconscionable contracts; we run out of adjectives before we run out of PBM issues.
- [Prime Therapeutics and Express Scripts Partnership Muddies On-site Audits and Results](https://paasnational.com/prime-therapeutics-and-express-scripts-partnership-muddies-on-site-audits-and-results/): This partnership was designed to allow both companies to operate independently with ESI providing services to Prime, including performing some audits.
- [Who’s Initiating Your Audit – Plan Sponsor, PBM or Audit Contractor?](https://paasnational.com/whos-initiating-your-audit-plan-sponsor-pbm-or-audit-contractor/): There are numerous entities that may initiate and perform pharmacy audits. While the actual audit process does not vary significantly, there are a few important nuances to understand.
- [Best Practice for Entering Transfers with Partial Refills Remaining](https://paasnational.com/best-practice-for-entering-transfers-with-partial-refills-remaining/): Transfer prescriptions carry a high audit risk due to the additional documentation required based on state regulations.
- [Copays for Pharmacy Staff and Family](https://paasnational.com/copays-for-pharmacy-staff-and-family/): PAAS National® analysts occasionally field questions related to copay collection, particularly with respect to prescriptions for pharmacy employees and their families.
- [New Dispensing Platform? Be Ready in Case of an Audit!](https://paasnational.com/new-dispensing-platform-be-ready-in-case-of-an-audit/): Pharmacies updating or changing their dispensing platform may face unique audit issues.
- [On-Demand Webinar: Compliance Issues, HIPAA Enforcement and Audit Risks with COVID-19](https://paasnational.com/on-demand-webinar-compliance-issues-hipaa-enforcement-and-audit-risks-with-covid-19/): On April 7, 2022 PAAS National® hosted Compliance Issues, HIPAA Enforcement and Audit Risks with COVID-19 webinar.
- [Are Your Patients Running Out of Supplies for Their Continuous Glucose Monitor?](https://paasnational.com/are-your-patients-running-out-of-supplies-for-their-continuous-glucose-monitor/): Pharmacies often struggle with audits for DMEPOS items. The Medicare Part B/DMEPOS billing model is a complex maze of units, codes and documentation requirements that are very different from billing traditional prescription drugs.
- [Updated COVID-19 Vaccine Attestations Plus Resource and Billing Chart on PAAS Member Portal](https://paasnational.com/updated-covid-19-vaccine-attestations-plus-resource-and-billing-chart-on-paas-member-portal/): On March 29, 2022, the CDC and FDA issued press releases to provide updated COVID-19 vaccine recommendations.
- [Yes, OTC COVID-19 Tests Can Be Audited!](https://paasnational.com/yes-otc-covid-19-tests-can-be-audited/): Dispensing OTC COVID-19 tests is widespread through community pharmacies. Pharmacies must be aware that submitting claims to PBMs for these tests opens the window for auditing. Ensuring you have procedures in place to accurately purchase, bill and dispense these home tests is imperative. While the dollar amount of these claims does not seem audit worthy, PBMs will be checking for Fraud, Waste and Abuse and contract violations.
- [Medi-Span® Generic Product Identifier](https://paasnational.com/medi-span-generic-product-identifier/): Health Information Technology vendors in the pharmacy industry utilize large drug compendia databases to manage electronic drug files so that electronic transactions are all “speaking the same language”.
- [Audit Issue: Patient or Prescriber Denials of Prescriptions](https://paasnational.com/audit-issue-patient-or-prescriber-denials-of-prescriptions/): PAAS National analysts have seen numerous PBM audit results where pharmacies had recoupments related to patient or prescriber denials of medications. Pharmacies are able to appeal by obtaining signed statements to overturn the denials.
- [Small Differences Between Prescription Directions and Patient Label Can Lead to BIG Recoupments](https://paasnational.com/small-differences-between-prescription-directions-and-patient-label-can-lead-to-big-recoupments/): PAAS National recommends attention to detail when it comes to typing directions for patient labels.
- [LIVE WEBINAR APRIL 7th: Compliance Issues, HIPAA Enforcement and Audit Risks with COVID-19](https://paasnational.com/live-webinar-april-7th-compliance-issues-hipaa-enforcement-and-audit-risks-with-covid-19/): Join President of PAAS National, Trenton Thiede, PharmD, MBA as he discusses compliance program requirements, recent HIPAA enforcement/action, COVID-19 vaccine audit risks, OTC COVID-19 tests audit risks (and Medicare B guidance) and onsite audit preparation.
- [Insulin for a Pump – Medicare B or Medicare D?](https://paasnational.com/insulin-for-a-pump-medicare-b-or-medicare-d/): Be sure you know how to correctly bill your patients’ insulin.
- [Caremark Complex Compounds](https://paasnational.com/caremark-complex-compounds/): PAAS National® analysts have recently worked with multiple pharmacies that received Compound Contract Violation notices from Caremark stating that the pharmacy must cease and desist submitting claims for “complex compounds” and reverse claims provided on an attached list.
- [Cash Copay Collection](https://paasnational.com/cash-copay-collection/): Numerous PBMs are conducting audits and asking for proof of copay collection.
- [Billing the Correct Insulin for Use in a Pump](https://paasnational.com/billing-the-correct-insulin-for-use-in-a-pump/): Insulin is a very popular audited drug category due to its complexity, frequency of use, and high cost. When used in conjunction with an insulin pump, it adds another layer of complexity.
- [Beware and Be Ready! In-Person Onsite Audits Are Resuming](https://paasnational.com/beware-and-be-ready-in-person-onsite-audits-are-resuming/): OptumRx and Express Scripts recently sent notices to pharmacies informing them in-person onsite audits will be starting back up in April.
- [Hackers Don’t Sleep, Your PHI is At Risk! What Are Your Safeguards?](https://paasnational.com/hackers-dont-sleep-your-phi-is-at-risk-what-are-your-safeguards/): Pharmacies, big and small, may find themselves on the probing end of a hacker’s criminal scheme designed to access and steal protected health information (PHI).
- [Humana Compliance Requirements – Training and Exclusion Checks Are Not Enough](https://paasnational.com/humana-compliance-requirements/): PAAS analysts have received several questions regarding Humana’s 2022 Notice of Program Requirements.
- [Options for DMEPOS Orders with Quantities Above Policy Limits](https://paasnational.com/options-for-dmepos-orders-with-quantities-above-policy-limits/): Medicare has strict coverage qualifications and limitations for items covered by Part B.
- [Self-Audit Series #14: DMEPOS Items](https://paasnational.com/self-audit-series-14-dmepos-items/): Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims – if you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems. 
- [Off-Label Use Not Covered Under Medicare Part D](https://paasnational.com/off-label-use-not-covered-under-medicare-part-d/): PAAS National® has seen an increase in audit results from Elixir where the pharmacy was cited for “Claim not covered under Medicare Part D (NPD).”
- [Medicare Not Enforcing Clinical Indications for Certain DMEPOS Categories During the COVID-19 PHE](https://paasnational.com/medicare-not-enforcing-clinical-indications-for-certain-dmepos-categories-during-the-covid-19-phe/): On March 13, 2020, HHS authorized many waivers and modifications regarding Medicare Part B and DMEPOS claims to help prevent gaps in access to care for patients affected by the PHE.
- [Best Practices for Vaccine Documentation](https://paasnational.com/best-practices-for-vaccine-documentation/): Without question, vaccine claims are on the rise! Consider a few best practices to reduce your risk of audit recoupments.
- [Billing OTC COVID-19 Tests Brings New Struggles and Opportunities](https://paasnational.com/billing-otc-covid-19-tests-brings-new-struggles-and-opportunities/): As of January 15, 2022, pharmacies are capable of billing up to eight at-home COVID-19 tests per covered individual per month.
- [Four Tips for Navigating Pharmacy Compliance Audits in 2022](https://paasnational.com/four-tips-for-navigating-pharmacy-compliance-audits-in-2022/): Compliance audits launched by pharmacy benefit managers (PBMs) have long been a cause of frustration for pharmacies, especially independent community pharmacies with limited manpower and resources compared to large chains.
- [Pharmacies Face Extra Audit Burdens That Threaten Their Existence](https://paasnational.com/pharmacies-face-extra-audit-burdens-that-threaten-their-existence/): The average audit in 2020 cost pharmacies $23,978, 35% more than the annual average over the previous five years, the PAAS data shows. And the number of prescriptions reviewed in September and October was fourfold over what PAAS members had seen in previous years.
- [Top 10 PAAS National Articles of 2021](https://paasnational.com/top-10-paas-national-articles-of-2021/): PAAS Audit Assistance members receive a monthly newsletter with new audit tactics and prevention tips.
- [Top 3 PAAS eNewsline Exclusive Articles](https://paasnational.com/top-3-paas-enewsline-exclusive-articles/): PAAS Audit Assistance member can explore additional eNewsline articles on the PAAS Member Portal.
- [2022 Fraud, Waste & Abuse and HIPAA Compliance Program Updates](https://paasnational.com/2022-fraud-waste-abuse-and-hipaa-compliance-program-updates/): The PAAS National® FWA/HIPAA Compliance Program has implemented changes to ensure pharmacies continue to have a robust program i
- [West Virginia Community Pharmacists: Are you prepared?](https://paasnational.com/west-virginia-community-pharmacists-are-you-prepared/): There is a new Health Care Fraud Strike Force focused on uncovering fraud, waste and abuse in West Virginia.
- [New OTC COVID-19 Resources for Community Pharmacies](https://paasnational.com/new-otc-covid-19-resources-for-community-pharmacies/): On February 2, PAAS National announced new COVID-19 resources for PAAS Audit Assistance members to aid in billing commercial third-parties for OTC COVID-19 tests. 
- [Caremark® Turns Up the Heat on Proof of Copay Collection Requests](https://paasnational.com/caremark-turns-up-the-heat-on-proof-of-copay-collection-requests/): PAAS National® is seeing a rising number of Caremark® audits requesting proof of copay collection. This requested information may be included in a desk, virtual onsite, or invoice audit. The number of claims requested can range from just a few claims to all dates of fill for several prescriptions.
- [Self-Audit Series #13: Diabetic Test Strips](https://paasnational.com/self-audit-series-13-diabetic-test-strips/): Due to the high volume of claims for diabetic test strips, they continue to receive significant attention during third-party audits. Follow the tips below to be prepared if you get an audit.
- [Are You Prepared to Prove TIRF REMS Program Compliance?](https://paasnational.com/are-you-prepared-to-prove-tirf-rems-program-compliance/): If your pharmacy dispenses Actiq®, Fentora®, Subsys®, or other medications which fall under the TIRF program, now is a good time to evaluate your compliance with all TIRF REMS requirements.
- [COVID-19 Oral Therapeutics Antiviral Billing Guidance](https://paasnational.com/covid-19-oral-therapeutics-antiviral-billing-guidance/): Two oral products have received Emergency Use Authorization for the treatment of COVID-19 infection – PaxlovidTM (Pfizer) and Molnupiravir (Merck).
- [Caremark® Expands “Aberrant” Language & Restricts Bulk Purchases](https://paasnational.com/caremark-expands-aberrant-language-restricts-bulk-purchases/): As mentioned in PAAS’ December 2021 Newsline article about PBM provider manual updates, Caremark® traditionally mails a paper hardcopy of their full provider manual on even years, and only amendments on odd years. With 2022 being an even year, contracted pharmacies should have received a full paper copy of the 2022 provider manual.
- [Top Medications Flagged for Unauthorized Substitutions](https://paasnational.com/top-medications-flagged-for-unauthorized-substitutions/): PAAS National® analysts have repeatedly seen auditors targeting claims with potentially undocumented substitution issues. They hope to find inappropriate substitutions which may result in recoupment of the claim.
- [Bill It Right: V-Go® Insulin Delivery Device and Rapid Acting Insulin Vials](https://paasnational.com/bill-it-right-v-go-insulin-delivery-device-and-rapid-acting-insulin-vials/): The Valeritas V-Go® Insulin Delivery Device (V-Go®), a disposable insulin delivery device, can be challenging to bill properly.
- [Manipulating Quantity or Days’ Supply to Bypass Plan Limits Will Cost You](https://paasnational.com/manipulating-quantity-or-days-supply-to-bypass-plan-limits-will-cost-you/): Plan limit rejections are intended to help control costs, provide clinical edits, and assist pharmacies in ensuring patient safety. When an initial claim adjudication is rejected for exceeding plan limits (e.g., Max Quantity Limit or Quantity vs Time Limit), pharmacies need to proceed with caution.
- [Self-Audit Series #12: Invoice Audits](https://paasnational.com/self-audit-series-12-invoice-audits/): PBMs have dramatically increased the number of invoice audits conducted and some pharmacies continue to be at risk for significant financial recoupments and contract terminations.
- [Common Claim Denials for Medicare Part B](https://paasnational.com/common-claim-denials-for-medicare-part-b/): Many of the denied claims are due to not meeting medical necessity, frequency limitations, lacking supporting medical records and even basic coding mistakes.
- [Transfer Prescriptions Continue to Be Targeted](https://paasnational.com/transfer-prescriptions-continue-to-be-targeted/): Transferred prescriptions remain a common audit target, and pharmacies are facing recoupments due to missing information.
- [Would Your Spravato® Documentation PAAS an Audit?](https://paasnational.com/would-your-spravato-documentation-paas-an-audit/): Spravato® is a Schedule III controlled substance intranasal spray used in conjunction with an oral antidepressant for treatment-resistant depression in adults
- [As Seen in Fortune: Pharmacies Face Extra Audit Burdens ...](https://paasnational.com/as-seen-in-fortune-pharmacies-face-extra-audit-burdens/): Trent Thiede, president of PAAS National, said many of the more than 5,000 pharmacies he works with stepped up to offer covid testing and shots and to become an even bigger resource for customers during this health crisis. “With vaccinations in full swing, priorities should be focused on serving patients and our communities, not responding to audit requests,” Thiede said.
- [OIG and GSA Exclusion Checking - Are You Compliant?](https://paasnational.com/oig-and-gsa-exclusion-checking-are-you-compliant/): The United States Department of Justice recently released the outcome of an investigation of the False Claims Act. Two pharmacists and their management company in Pennsylvania agreed to pay $250,000 to resolve the potential liability.
- [Self-Audit Series #6: Transfer Prescriptions](https://paasnational.com/self-audit-series-6-transfer-prescriptions/): Transferred prescriptions are at high risk for audit recoupment. The PBMs are hitting pharmacies on incomplete transferred prescriptions based on missing required elements.
- [MedImpact is Turning Up the Heat on FWA Investigations](https://paasnational.com/medimpact-is-turning-up-the-heat-on-fwa-investigations/): PAAS National® has recently received several FWA audit results requiring the pharmacy to submit additional, and arduous, supporting documentation. Pharmacies need to be aware of the audit risks for medications with high Average Wholesale Prices (AWP) and narrow FDA approved indications (e.g., Pennsaid®). Significant time and effort must be put forth by the pharmacy, prescriber and potentially the patient, to support these claims.
- [Telemedicine Audits: Are Your Prescriptions Legitimate?](https://paasnational.com/telemedicine-audits-are-your-prescriptions-legitimate/): Unfortunately, telemedicine also continues to be an easy target for bad actors, with pharmacies being caught in the middle.
- [OptumRx Prohibits Mailing Prescriptions](https://paasnational.com/optumrx-prohibits-mailing-prescriptions/): Optum has recently faxed out notices reminding pharmacies that they should not solicit members for mail delivery or mail any covered prescription services.
- [The CVS Caremark and Aetna Deal](https://paasnational.com/the-cvs-and-aetna-deal/): Some say the deal to merge CVS Caremark and Aetna will be bad for health care. The $69 billion merger could have major implications for patients.
- [Opioids - Don't Get Sucked In!](https://paasnational.com/opioids-dont-get-sucked-in/): “Two pharmacists sentenced to 19 and 20 years in prison and ordered to pay $5 million in restitution to the state of Georgia to combat the opioid epidemic,” reads the news heading from the Department of Justice story based upon the criminal activity of two pharmacists. “Rosemary Ofume and Donatus Iriele have each been ordered to
- [Humana Slamming Pharmacies for Invalid Faxed and Oral Prescriptions](https://paasnational.com/humana-slamming-pharmacies-for-invalid-faxed-and-oral-prescriptions/)
- [ESI Enforcing Mail Order and Formulary Limits](https://paasnational.com/esi-enforcing-mail-order-and-formulary-limits/): PAAS recently became aware of Express Scripts (ESI) enforcing their mail order and formulary compliance limitations. Several pharmacies have received Cease & Desist notices from ESI and even one contract termination notice. ESI is using patient address information to make assumptions as to which claims are being mailed outside of the pharmacy’s service area because
- [Walmart, Sam’s Club Fined $825,000 for Auto Refills](https://paasnational.com/walmart-sams-club-fined-825000-for-auto-refills/)
- [Expect Medicaid Managed Care Plans to Drastically Increase Audits](https://paasnational.com/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
- [Humana Begins Enforcing Mail Order Prohibition](https://paasnational.com/humana-begins-enforcing-mail-order-prohibition/)
- [Generic Albuterol HFA Inhalers](https://paasnational.com/generic-albuterol-hfa-inhalers/)
- [Patient Copay Collection, and Documentation, is a MUST](https://paasnational.com/patient-copay-collection-and-documentation-is-a-must/)
- [Authorized Generic vs. ANDA Generic](https://paasnational.com/authorized-generic-vs-anda-generic/)
- [Test Claims are Prohibited and Put Pharmacies at Risk](https://paasnational.com/test-claims-are-prohibited-and-put-pharmacies-at-risk/)
- [Pharmacist Sentenced to 10 Years in Prison for Fraud Scheme](https://paasnational.com/pharmacist-sentenced-to-10-years-in-prison-for-fraud-scheme/)
- [Prime Recovering Claims on Drug Substitutions](https://paasnational.com/prime-recovering-claims-on-drug-substitutions/)
- [Split Billing Opioid Prescriptions](https://paasnational.com/split-billing-opioid-prescriptions/)
- [Disputing Humana’s Bogus $5 Administrative Fees](https://paasnational.com/disputing-humanas-bogus-5-administrative-fees/)
- [With USP <795> and <797> on Hiatus, Time to Focus on USP <800>](https://paasnational.com/with-usp-795-and-797-on-hiatus-time-to-focus-on-usp-800/)
- [Caremark Strictly Enforces Coupon Policy](https://paasnational.com/caremark-strictly-enforces-coupon-policy/)
- [OptumRx/SCIO Targeting Part B Drugs & Supplies](https://paasnational.com/optumrx-scio-targeting-part-b-drugs-supplies/)
- [Stop Breaking Insulin Pen Boxes](https://paasnational.com/stop-breaking-insulin-pen-boxes/)
- [Auditors Scrutinize Printed Electronic Prescriptions!](https://paasnational.com/auditors-scrutinize-printed-electronic-prescriptions/)
- [GoodRx Shares Consumer Data](https://paasnational.com/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
- [Auditors Targeting Ladder Schedule II Prescriptions](https://paasnational.com/auditors-targeting-ladder-schedule-ii-prescriptions/)
- [PBMs Require “Cut Quantity” Documentation](https://paasnational.com/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”.
- [Stop Breaking Insulin Pen Boxes– Your Questions Answered](https://paasnational.com/stop-breaking-insulin-pen-boxes-your-questions-answered/): 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.
- [PBMs Enforcing Return to Stock Policies](https://paasnational.com/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.
- [Caremark Enforcement: Aberrant Quantities & Volumes](https://paasnational.com/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!.
- [COVID-19 Audit Considerations Follow-Up](https://paasnational.com/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.
- [Smartphones Put Pharmacies at Risk for Inappropriate PHI Disclosures](https://paasnational.com/smartphones-put-pharmacies-at-risk-for-inappropriate-phi-disclosures/): 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.
- [Medicare Part B Requires a Claim Modifier If You Are Not Collecting Patient Signatures!](https://paasnational.com/medicare-part-b-requires-a-claim-modifier-if-you-are-not-collecting-patient-signatures/)
- [Authorized Distributors for Diabetic Test Strips](https://paasnational.com/authorized-distributors-for-diabetic-test-strips/): Invoice audits focusing on diabetic test strips are common in the PBM world.
- [Defense Health Agency Money Grab for 2015 Prescriptions Involves Over 300 Pharmacies](https://paasnational.com/defense-health-agency-money-grab-for-2015-prescriptions-involves-over-300-pharmacies/): June delivered a bombshell for over 300 pharmacies when Express Scripts recouped payment for TRICARE prescriptions dating back to 2015. These recoupments occurred before pharmacies were even notified, leaving many struggling to make payroll and pay wholesalers - in the middle of a Pandemic.
- [Ozempic®– Bill It Right!](https://paasnational.com/ozempic-bill-it-right/): Ozempic® is an injectable used to improve glycemic control in adults with type 2 diabetes mellitus and is available as 2 mg in a 1.5 mL (1.34 mg/mL) pre-filled, disposable pen injector.
- [BEWARE: Virtual On-Site Audits Are Coming!](https://paasnational.com/beware-virtual-on-site-audits-are-coming/): If you haven’t already noticed, most of the PBMs have resumed auditing practices and started issuing on-site audits the first week of August; however, these are not the on-site audits that you are used to.
- [Foot Bath Prescriptions - MedImpact is Now the Fifth PBM Investigating](https://paasnational.com/foot-bath-prescriptions-medimpact-is-now-the-fifth-pbm-investigating/): PAAS National has alerted members through several Newsline articles of an increase in audits with Prime Therapeutics®, Caremark®, OptumRx® and Express Scripts® investigating foot bath prescriptions.
- [Nine Pharmacists Charged in $12 Million Fraud Related to Invoice Shortages](https://paasnational.com/nine-pharmacists-charged-in-12-million-fraud-related-to-invoice-shortages/): Nine pharmacists were recently indicted on felony charges in a $12.1 million health care fraud scheme according to a June 17, 2020 U.S. Department of Justice press release.
- [COVID-19 Vaccine: Are You Prepared to Administer?](https://paasnational.com/covid-19-vaccine/): Healthcare providers will play a key role when a COVID-19 vaccine becomes available.
- [FDA Guidance on Insulin Pens Puzzling](https://paasnational.com/insulin-pens/): On October 13, 2020, the U.S. Food and Drug Administration issued a statement looking to clarify the intent of the November 2019 label revisions for insulin pens.
- [Mid-Level Practitioners and Their Supervising Physicians– Documentation Required?](https://paasnational.com/mid-level-practitioners-and-their-supervising-physicians-documentation-required/): PAAS National has seen a recent uptick in the number of prescriptions being found discrepant for missing the supervising physician when written by a mid-level practitioner (e.g. physician assistant or nurse practitioner).
- [PBM Enforcement of Return to Stock Policies](https://paasnational.com/pbm-enforcement-of-return-to-stock-policies/): A PBM will recoup a claim in full if a medication is picked up after their required return to stock timeframes listed in the respective provider manuals.
- [Caremark Manufacturer Coupon Policy](https://paasnational.com/caremark-manufacturer-coupon-policy/): PAAS National continues to see pharmacies suffer full recoupment on claims that are processed to coupons and copay cards in violation of Caremark’s policy found in section 3.03.03 of the 2020 Pharmacy Provider Manual.
- [FDA Requests Updated Product Labeling on Insulin Pens](https://paasnational.com/urgentinsulinalert/): The pharmacy industry has long debated whether one box of insulin pens is considered “unbreakable”. The debate appeared to be settled January 22nd, 2019 when the U.S. Department of Justice issued a press release stating Walgreens agreed to a $209 million fraud settlement with the federal government regarding its billing and dispensing of insulin pens to Medicaid, Medicare Part D and TRICARE patients. Prior to the settlement, Walgreens’ policy was to not dispense any insulin pens in quantities less than one full box, forcing their staff to falsely understate the days’ supply on thousands of claims.
- [Webinar: 340B Contract Pharmacy Considerations for 2021](https://paasnational.com/340b-contract-pharmacy-considerations-for-2021/): PAAS National is hosting a 340B Contract Pharmacy Considerations for 2021 webinar.
- [340B Contract Pharmacy Claims Identification and Submission Requirements](https://paasnational.com/340b/): For 2021, a major PBM updated their provider manual regarding their position on the 340B drug discount program.
- [Are You Documenting DUR and Submission Clarification Codes?](https://paasnational.com/are-you-documenting-dur-and-submission-clarification-codes/)
- [Fraud, Waste, & Abuse and HIPAA Compliance Updates for 2021](https://paasnational.com/fraud-waste-abuse-and-hipaa-compliance-updates-for-2021/): PAAS National® continuously keeps close tabs on legislative and regulatory changes that may impact our members’ Fraud, Waste & Abuse and HIPAA Compliance Program.
- [Updated Dispense in Original Container Chart](https://paasnational.com/updated-dispense-in-original-container-chart/): Medications that are required to be dispensed in their original container continue to appear in audits.
- [Pitfalls of Transferred Prescriptions](https://paasnational.com/pitfalls-of-transferred-prescriptions/): Transferred prescriptions are at high risk for audit recoupments. Every element required by state regulations is one additional pitfall that PBMs utilize to try and recoup on claims.
- [FWA and HIPAA Compliance with Job Shadows and Interns](https://paasnational.com/fwa-and-hipaa-compliance-with-job-shadows-and-interns/): Students performing a job shadow or internship in the pharmacy need proper FWA/HIPAA training and preparation to be behind the pharmacy counter or you are inviting headaches into your operations (and potential legal complications).
- [COVID-19 Vaccine Billing Guidance](https://paasnational.com/covid-19-vaccine-billing-guidance/): The coverage for COVID-19 vaccine may be under the pharmacy benefit (via NCPDP standard) or the medical benefit (via CPT codes). Here is a summary of billing information known to PAAS National® as of December 23, 2020.
- [COVID-19 Vaccine Billing Guidance (April Update)](https://paasnational.com/covid-19-vaccine-billing-guidance-april-update/): PAAS National® has seen a few COVID-19 vaccine audits since pharmacies began billing and administering within the last few months. This article contains some reminders and updates from our January 2021 Newsline COVID-19 Vaccine Billing Guidance.
- [Webinar: Thriving Against PBM Audits – Audit Trends and PBM Tactics](https://paasnational.com/webinar-thriving-against-pbm-audits-audit-trends-and-pbm-tactics/): On June 23, 2021 PAAS National® hosted Thriving Against PBM Audits – Audit Trends and PBM Tactics webinar. PAAS Audit Assistance members have access to the recorded webinar, in addition to many other tools and resources on the PAAS Member Portal.
- [Celebrating 1 Year of License Tracking with the PAAS Vault](https://paasnational.com/celebrating-1-year-of-license-tracking-with-the-paas-vault/): “Our pharmacy was previously in the need of a better way to track the expiration of our licenses, certificates, insurance, contracts, etc. The PAAS vault provided us the ability to have one web-based platform that was able to house the necessary documents needed to maintain compliance as well as track upcoming expiration dates. The trial has been very valuable. It has allowed me to play around with the features of this new service and see first-hand the benefit it provides to our compliance program. The part I like best is that I can attach physical documents as well as enter expiration dates where I can quickly see on the dashboard page upcoming expirations that need to be addressed. I would like to be able to use this service in an expanded way in the future. For example being able to store payer audit documents/findings, board of pharmacy inspection reports, and payer contracts for easy retrieval.”
- [Announcing the new PAASNational.com](https://paasnational.com/announcing-the-new-paasnational-com/): After many months of hard work and dedication from our team, we are pleased to announce that on June 22, 2021 we launched the new PAAS National® website paasnational.com.
- [AmerisourceBergen ThoughtSpot 2021: Navigating Pharmacy Audits Amidst a Pandemic](https://paasnational.com/amerisourcebergen-thoughtspot-2021-navigating-pharmacy-audits-amidst-a-pandemic/): Pharmacy audits continue to morph as Pharmacy Benefit Managers (PBMs) develop new methods to recoup prescription claims. Understanding the many facets of the audit process, including triggers, trends, and prevention strategies will enable your pharmacy to be more successful in an audit situation.
- [Facing Potential Disciplinary Action? PBMs Require Notification!](https://paasnational.com/facing-potential-disciplinary-action-pbms-require-notification/): It can be a very stressful time for a pharmacy when they, or an employee, are being investigated by a regulatory body (e.g., Board of Pharmacy, Office of Inspector General (OIG) or Drug Enforcement Agency).
- [Pharmacies Facing More Payment Denials During Pandemic's Virtual Audits](https://paasnational.com/pharmacies-facing-more-payment-denials-during-pandemics-virtual-audits/): Already marred from COVID-19 burnout and years of financial threats, independent pharmacies' latest woe is pharmacy benefits managers' shift to virtual audits during the pandemic.
- [PHI Access and Release for Deceased Patients](https://paasnational.com/phi-access-and-release-for-deceased-patients/): According to the Office for Civil Rights (OCR), the Privacy Rule allows for pharmacies to disclose PHI about a deceased patient to person(s) involved in the individual’s health care prior to their death, unless doing so is going against the patient’s documented requests.
- [Humana Notice of Erroneous Billing under Medicare’s Limited Income Newly Eligible Transition Program (LINET)](https://paasnational.com/humana-notice-of-erroneous-billing-under-medicares-limited-income-newly-eligible-transition-program-linet/): PAAS National® has received an exorbitant number of audits from Humana, the administrator for the LINET program, in the past two weeks.
- [Medicare Part D Audits: Top 11 Areas for Scrutiny](https://paasnational.com/medicare-part-d-audits-top-11-areas-for-scrutiny/): Medicare Part D pharmacy audits are on the rise, and pharmacists would be wise to adapt their business practices and know how to respond. Trent Thiede presented the top 11 audit discrepancy areas.
- [Audit Risk: Ivermectin Used for Treating COVID-19 (September Update)](https://paasnational.com/audit-risk-ivermectin-used-for-treating-covid-19-september-update/): Dangers of using Ivermectin to treat or prevent COVID-19. PAAS is seeing more PBM audits on ivermectin prescriptions. Pharmacies should be prepared!
- [Hope to See You This Fall at the NCPA Annual Convention!](https://paasnational.com/hope-to-see-you-this-fall-at-the-ncpa-annual-convention/): This fall, visit the PAAS team at the NCPA 2021 Annual Convention in Charlotte, NC on October 9-12, 2021. Trent Thiede will be at the premier event for community pharmacy owners.
- [Safeguarding ePHI – Office for Civil Rights (OCR) Summer Update](https://paasnational.com/safeguarding-ephi-office-for-civil-rights-ocr-summer-update/): Safeguarding patient’s electronic PHI (ePHI) is a top priority for all who work in healthcare. Unfortunately, tactics hackers use to access ePHI have become more sophisticated and occur with an increasing frequency.
- [LifeScan Hires Law Firm to Pursue Pharmacies Purchasing from Unauthorized Distributors](https://paasnational.com/lifescan-hires-law-firm-to-pursue-pharmacies-purchasing-from-unauthorized-distributors/): Test strip manufacturers sit in a unique position when it comes to monitoring nonprescription diabetic supply purchasing and dispensing. Manufacturers acquire purchase histories from authorized distributors regarding the volume of test strip products ordered by a pharmacy.
- [Humana Audit Program Updates](https://paasnational.com/humana-audit-program-updates/): On July 1, 2021 Humana updated three audit program documents and published them on their public pharmacy resources page under the “Manuals and forms: Audit guide, claim form and other materials” tab section.
- [Getting Help with an Audit](https://paasnational.com/getting-help-with-an-audit/): Oh no! You just received an audit, now what? First step is to get your audit notice to PAAS National as soon as you receive them.
- [COVID-19 Vaccine Administration Audit Risk (including New PAAS Resource)](https://paasnational.com/covid-19-vaccine-administration-audit-risk-including-new-paas-resource/): With additional doses of the COVID-19 vaccine being approved comes additional opportunities for COVID-19 audits, particularly in the realm of vaccine administration to Medicare beneficiaries at their homes and to the immunocompromised patient population.
- [Billing Insulin & Related Supplies – Medicare Part B vs Part D](https://paasnational.com/billing-insulin-related-supplies-medicare-part-b-vs-part-d/): PAAS National® analysts frequently field questions about billing insulin and related supplies – this can be particularly confusing when the patient has Medicare coverage. Coverage of insulin and related supplies may depend on both the type of Medicare benefit and how the item is being used. Specifically, insulin vials and alcohol swabs could be covered under either Medicare Part B or Part D!
- [Are You Violating PBM Return to Stock Policies? (including New PAAS Chart)](https://paasnational.com/are-you-violating-pbm-return-to-stock-policies-including-new-paas-chart/): PAAS National® continues to see pharmacies losing money due to violating PBM Return to Stock policies. Each PBM sets a timeframe that unclaimed prescriptions must be reversed and returned to stock. Full recoupment of the claim can occur when a PBM discovers prescriptions are dispensed to patients outside this timeframe. Staying up to date on Return to Stock requirements is imperative.
- [Vaccinating Outside of Approved COVID-19 Emergency Use Authorization Has Legal Ramifications](https://paasnational.com/vaccinating-outside-of-approved-covid-19-emergency-use-authorization-has-legal-ramifications/): As reported in a September 27, 2021 article by the US Attorney’s Office, the owner of a pharmacy in Juana Díaz, Puerto Rico, “knowingly and willfully” administered vaccine outside of the Emergency Use Authorization (EUA) and subsequently billed Medicaid for the claims. Twenty-four children between 7-11 years of age were vaccinated with the Pfizer-BioNTech COVID-19 vaccine.
- [Stark Law and Anti-Kickback Violations –Indictments Handed Down for Medically Unnecessary Claims](https://paasnational.com/stark-law-and-anti-kickback-violations-indictments-handed-down-for-medically-unnecessary-claims/): According to a September 17, 2021 press release from the Department of Justice (DOJ), a podiatrist was indicted for defrauding Medicare and Medicaid “by prescribing and dispensing medically unnecessary foot bath medications.”
- [PREP Act Ninth Amendment – Overview and Audit Guidance for Subcutaneous REGEN-COV](https://paasnational.com/prep-act-ninth-amendment-overview-and-audit-guidance-for-subcutaneous-regen-cov/): The ninth amendment to the Public Readiness and Emergency Preparedness (PREP) Act was published in the Federal Register on September 14th, 2021, which granted pharmacists the authority to order and administer COVID-19 therapeutics and qualified pharmacy technicians and pharmacy interns to administer COVID-19 therapeutics under the supervision of a pharmacist.
- [LIVE WEBINAR NOV. 18: PBM FWA Trends and COVID-19 Vaccine Audit Risks](https://paasnational.com/live-webinar-nov-18-pbm-fwa-trends-and-covid-19-vaccine-audit-risks/): Join President of PAAS National, Trenton Thiede, PharmD, MBA for a LIVE webinar "PBM FWA Trends and COVID-19 Vaccine Audit Risks" on November 18, 2021 from 2-2:30pm CT as he discusses ...
- [Accepting Gifts Can Be an FWA Violation](https://paasnational.com/accepting-gifts-can-be-an-fwa-violation/): The U.S. Department of Justice issued a press release on September 30, 2021, outlining that a former public official accepted “gratuities” (aka gifts or kickbacks) in exchange for referring business to a specific outside vendor.
- [HIPAA Guidance Regarding COVID-19 Vaccination Status in the Workplace](https://paasnational.com/hipaa-guidance-regarding-covid-19-vaccination-status-in-the-workplace/): On September 30th, the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) released guidance regarding the Health Insurance Portability and Accountability Act (HIPAA) of 1996 Privacy Rule and its application to the workplace, specifically discussing the disclosure and request of COVID-19 vaccination status.
- [Updated PAAS National® Dispense In Original Container Chart](https://paasnational.com/updated-paas-national-dispense-in-original-container-chart/): Dispensing medications outside of FDA packaging requirements may put your claims at risk of recoupment. Medications sensitive to light and/or moisture may require pharmacies to dispense the medication in the original container.
- [Centene® – Why Are They Leaving the PBM Game?](https://paasnational.com/centene-why-are-they-leaving-the-pbm-game/): At the end of October 2021, Centene® executives said the company would be making a $30 billion request for proposals from outside contractors to take over the pharmacy benefit manager (PBM) side of their business. The request for proposal is expected to launch in 2022 and be awarded in 2023.
- [Update: Medicare Part D Mandatory e-Prescribing Requirements](https://paasnational.com/update-medicare-part-d-mandatory-e-prescribing-requirements/): armacies to the delay in enforcement of Electronic Prescriptions for Controlled Substances (EPCS) for Medicare Part D until January 1, 2022.
- [Bill it Right: AndroGel® Pump 88 g vs 75 g](https://paasnational.com/bill-it-right-androgel-pump-88-g-vs-75-g/): Pharmacies have recently reported receiving telephone calls from Caremark’s audit department regarding claims for AndroGel® (testosterone) pump (and generics) related to incorrect package size billed.
- [PBM Provider Manual Updates – What You Need to Know](https://paasnational.com/pbm-provider-manual-updates-what-you-need-to-know/): Pharmacy Benefit Managers (PBMs) update their provider manuals on occasion (some more frequently than others) and although the changes are applicable to the practice of all pharmacies contracted with that PBM, it can be difficult to keep track of the method by which each PBM updates their manual and where to find it.
- [Beware: Same Ingredients, Different FDA Indications](https://paasnational.com/beware-same-ingredients-different-fda-indications/): Ozempic® is an injectable diabetic medicine used to improve glycemic control in adults for type 2 diabetes management
- [Don’t Jump the Gun: Refill Too Soon Recoupments](https://paasnational.com/dont-jump-the-gun-refill-too-soon-recoupments/): Pharmacies know the importance of billing accurate days’ supply on prescriptions; however, there may be circumstances that can make this challenging.
- [Webinar: PBM FWA Trends and COVID-19 Vaccine Audit Risks](https://paasnational.com/webinar-pbm-fwa-trends-and-covid-19-vaccine-audit-risks/): On November 18, 2021 PAAS National® hosted PBM FWA Trends and COVID-19 Vaccine Audit Risks webinar. PAAS Audit Assistance members have access to the recorded webinar, in addition to many other tools and resources on the PAAS Portal.

## Pages

- [Home](https://paasnational.com/): Helping Community Pharmacies Gain Confidence and Peace of Mind
- [Buy Now](https://paasnational.com/buy-now/): One flat annual fee, no added charges. The all-inclusive membership includes both, Audit Assistance and FWA/HIPAA Compliance programs, plus one year FREE of license tracking with the PAAS Vault.
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- [Why Join Us](https://paasnational.com/why-join-us/): Over 5K pharmacies in all 50 states and Puerto Rico. PAAS is the industry-leading advocate and defender of community pharmacy dealings with Prescription Benefit Programs. PAAS helps fight for fair audit treatment, and is a guiding light, steering community pharmacists away from trouble and toward compliance with rules and regulations such as HIPAA and Fraud, Waste and Abuse.
- [Meet the Team](https://paasnational.com/meet-the-team/): The team at PAAS National® is dedicated to helping you survive predatory audits, compliance issues, or whatever new trick PBMs are springing on you. PAAS continuously updates their database with information on thousands of types of audits — in fact we even keep a scorecard on individual auditors.
- [Staff Bio - Heaven](https://paasnational.com/staff-bio-heaven/)
- [News and Events](https://paasnational.com/news-and-events/): The team at PAAS National® is dedicated to helping you survive predatory audits, compliance issues, or whatever new trick PBMs are springing on you. The PAAS team is dedicated to helping you! We have five pharmacists and a complement of technician analysts with 56 years of dedicated audit assistance experience. PAAS continuously updates their certified database with information on thousands of audits — in fact, we even keep a scorecard on individual auditors.
- [Staff Bio - Lindsay](https://paasnational.com/staff-bio-lindsay/)
- [Staff Bio - Katie](https://paasnational.com/staff-bio-katie/)
- [Staff Bio - Kristen](https://paasnational.com/staff-bio-kristen/)
- [Staff Bio - Erin](https://paasnational.com/staff-bio-erin/)
- [Staff Bio - Trent](https://paasnational.com/staff-bio-trent/)
- [Staff Bio - Meredith](https://paasnational.com/staff-bio-meredith/)
- [Fraud, Waste & Abuse/HIPAA Compliance Program](https://paasnational.com/fwac-hipaa/): Don’t miss your opportunity to join the best compliance program available to community pharmacies. Avoid being caught off-guard!
- [Staff Bio - Maddie](https://paasnational.com/staff-bio-maddie/)
- [Staff Bio - Ashley](https://paasnational.com/staff-bio-ashley/)
- [Staff Bio - Jenevra](https://paasnational.com/staff-bio-jenevra/)
- [Staff Bio - Lanae](https://paasnational.com/staff-bio-lanae/)
- [Staff Bio - Hope](https://paasnational.com/staff-bio-hope/)
- [Staff Bio - Eric](https://paasnational.com/staff-bio-eric/)
- [Staff Bio - Mallory](https://paasnational.com/staff-bio-mallory/)
- [Staff Bio - Sara](https://paasnational.com/staff-bio-sara/)
- [](https://paasnational.com/bundletosave/)
- [PAAS Technologies Mobile App Privacy Policy](https://paasnational.com/paas-technologies/rx-calcs-privacy-policy/)
- [Rx Days’ Supply Calculator](https://paasnational.com/app/): Community pharmacists and technicians can calculate the appropriate quantity or days’ supply with ease using the PAAS National Technologies Rx Days’ Supply Calculator app.
- [License Tracking with the PAAS Vault](https://paasnational.com/paas-vault/): Everything you need to keep track of licenses, certifications, business documents, and other important pharmacy records.
- [Contact PAAS Technologies](https://paasnational.com/paas-technologies/contact-app-support/): PAAS National Technologies is committed to serving your needs and want to help you on questions you may have on the Rx Days' Supply Calculator app!
- [PAAS Technologies](https://paasnational.com/paas-technologies/)
- [Staff Bio - Stacy](https://paasnational.com/staff-bio-stacy/)
- [About Us](https://paasnational.com/about-us/): In 1993, Ed Heckman founded two companies: PAAS National® to help community pharmacies defend from unfair PBM audits and Compliant Pharmacy Alliance® (CPA).
- [Virtual Audits](https://paasnational.com/virtual-audits/)
- [Onsite Audits](https://paasnational.com/onsite-audits/)
- [OIG/Medicaid Audits](https://paasnational.com/oig-medicaid-audits/)
- [Med B Audits](https://paasnational.com/med-b-audits/)
- [Invoice Audits](https://paasnational.com/invoice-audits/)
- [Desktop Audits](https://paasnational.com/desktop-audits/)
- [340B Audits](https://paasnational.com/340b-audits/)
- [Refer a Friend](https://paasnational.com/refer-a-friend-s/)
- [Staff Bio - Jennifer](https://paasnational.com/staff-bio-jennifer/)
- [Staff Bio - Ed](https://paasnational.com/staff-bio-ed/)
- [Staff Bio - Dana](https://paasnational.com/staff-bio-dana/)
- [Refer a friend](https://paasnational.com/refer-a-friend/): Know someone great that needs are services? PAAS National® is the industry-leading advocate and defender of community pharmacy dealings with Prescription Benefit Programs. PAAS helps fight for fair audit treatment, and is a guiding light, steering community pharmacists away from trouble and toward compliance with rules and regulations such as HIPAA and Fraud, Waste and Abuse.
- [Schedule a time for a services overview](https://paasnational.com/schedule-a-1-1-meeting/)

## Categories

- [General](https://paasnational.com/category/general/)
- [FWA](https://paasnational.com/category/fwa/)
- [Audit](https://paasnational.com/category/audit/)
- [Cultural Competency](https://paasnational.com/category/cultural-competency/)
- [USP 800](https://paasnational.com/category/usp-800/)