Independent pharmacy audits

[VictorOfHungerGames]

Just moved from CVS to an independent. Had a quick question for those who have independent pharmacy experiences.

When working at CVS, I never had to deal with audits from insurance companies but I am told that it is normal for independent to be audited by insurances. Apparently, big companies like CVS have their own department to deal with audits?

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[Sabril]

independent faces a lot of audits. You can expect at least one a year. If you are the PIC or if your PIC is also your lazy boss, then it will fall on you to keep everything in order.

The smaller one is a desktop audit. Typically it comes from the insurance companies themselves. They give you a rx number and a date of service and want you to fax them the front and back of your prescription along with the patient's signature for that date of service. Then in a couple months they will let you know if there is any discrepancies and how much the chargeback will be. This is typically triggered because you submitted a claim with an unusual quantity and day supply- for example 3 bottles of lantus for 30 days- and their computer flags it. Caremark likes to do this.

The bigger one is in-pharmacy audit (*** hits the fan time). The third party payer will hire an audit company to come to your place. They will send you a notice on what date they will be there and how far back they will look at your record (typically two years). They won't tell you what specific prescriptions they come to look at. Typically they are after expensive items. They don't care if you miss a drug interaction and kill someone. They just want to take everything back so hang on to your underwear.

When the person is there, he or she will give you a list of all the rxs they need. You need all your hard copy rxs in order (they don't care what you scan into your system). You need your signature logs. You need to make sure your day supply is calculated correctly, origin codes, written date, doctor's npi etc.. all correct. Just the fact that your origin code is wrong (e.g., rx was a verbal order and someone keyed it in as a fax), you will stand to lose all of your reimbursement on every single fill of that prescription.

So those are the little things that you have to pay attention to everyday, not just around the time of the audit. Many pharmacists I know tend to miss out on them because they rely on the techs to get it right, but if your techs suck at typing then it will fall back on you.

 

[Chrissystone]

To add to this, if you have a high script volume for Medicaid, they may request your wholesaler purchase logs to make sure the ndc you're billing is the ndc you're giving.

A lot of pharmacies have ndcs that give the most reimbursement from Medicaid or is the only ndc that Medicaid accepts.

Things that come in ml and grams are also highly audited. For example lovenox, eye drops, insulins, sprays, pumps, creams, ointments. They want to make sure your quantity and days supply are reasonable.

 

[OXYFORALL]

If you have an audit coming most independent pharmacies can generate a report of rx's filled by that plan. We pull the high dollar rx's and check the rx's to make sure they have all the proper notes and documentation before the auditor shows up. Things like the wrong written date can be fixed with a quick note on the rx before the audit. After they show up its too late. Most of theses audits are fishing trips for the pbm to make easy money.