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.
PAAS National® has created a COVID-19 Resources section for our members on the PAAS Member Portal. Here you can find the Patient Request and Attestation for OTC COVID-19 Test Billing and Frequently Asked Questions. These documents have been created for our members to help answer questions and ease the documentation burden so pharmacies can save time and be audit ready.
Recently, a PAAS member received an audit request and results for an invoice audit targeting OTC COVID-19 tests. The audit was for a very short time frame and the PBM had already contacted patients to verify what manufacturer and quantity of tests the patient had received. Only tests that have been authorized by the FDA should be billed and dispensed. You can find a list of approved tests here.
- See the CMS website for guidance on billing Medicare for OTC COVID-19 tests
- Be sure you are ordering OTC COVID-19 tests from a reputable wholesaler, see our January 2022 Newsline article, Self-Audit Series #12-Invoice Audits
- Pharmacies doing a pharmacy-to-pharmacy transfer of product must have proper documentation, including proof of payment. For more information see our January 2019 Newsline article, Invoice Audits-Pharmacy to Pharmacy Inventory Transfers.
- The claim submitted to the PBM must match the NDC/UPC of the product dispensed
- Package size must be divisible by the quantity being dispensed
- Have patients complete a Patient Request and Attestation for OTC COVID-19 Test Billing for your records in case of audit
- See this month’s Newsline article on Patient (or Prescriber) Denials of Prescriptions