LTC Is Different … Do Auditors Agree?
PAAS National® analysts frequently assist pharmacies that service LTC facilities. Not only does PAAS work with many combo shops, but we also service numerous closed-door LTC pharmacies. The pharmacies servicing Skilled Nursing Facilities (SNFs) often struggle to provide the appropriate documentation that auditors look for. It is important to know most PBMs follow similar requirements for both retail and LTC during the audit process.
Three audit flags PAAS analysts frequently see for LTC pharmacies:
- Missing a valid order/prescription (consider reviewing Humana Guidelines for LTC)
- Patient Name
- Date of issuance
- Name of the Drug
- Strength of the Drug
- Dosage form of drug (if applicable)
- Directions for Use
Some of more common items that are missed or a concern to refresh pharmacy staff on are:
- Duration of Therapy (number of refills or clear start/stop dates, or a disclaimer regarding duration)
- Missing DEA Elements on Controlled Substances
- Prescriber’s printed name and signature on the physician order
- Billing and dispensing at inappropriate times
- Delivering prior to Billing
- Delivering outside the PBM’s Return to Stock window
- Insufficient documentation for signature/delivery logs
- Patient name
- Prescription number(s)
- Date filled or fill number
- Date of delivery to facility – cannot be pre-printed
- Facility name and address
- Signature and date of representative accepting delivery
- Proof that full amount billed was received
While standard for retail pharmacies, those servicing LTC facilities may fall short. Pharmacies should consider putting procedures in place to mitigate these issues during the audit process. Trying to obtain this information at the time of the audit, or appealing post-audit, can be very difficult and time consuming.
- Educate your staff and the facility staff on what documentation is required
- Engage PAAS as soon as you receive an audit, check out this month’s article First Step in Getting Help with an Audit
- See the PAAS Return to Stock chart for common PBM policies and be sure your deliveries are not exceeding this
- Review the following Newsline articles for additional tips:
- November 2022, Yes, LTC Delivery Manifests ARE Needed!
- February 2023, Are Your Delivery/Signature Logs PBM Compliant for 2023?
- December 2020, Appropriate Documentation for LTC Overrides Explained
- February 2020, Billing the Appropriate Medicare Part in LTC
- Ozempic® Package Size Change - June 1, 2023
- Nuances of Insulin Pens and How They May Differ - May 18, 2023
- PerformRxSM Investigational Audits Are on the Rise - April 26, 2023