PBM audit results

[Doctor M]

So, we were audited by a certain PBM. The auditors concluded the following:

chargebacks of $37,500 due to the following:

Several E-prescribes did not have the Doc-ID on them. These included Truvada, Lexiva and protonix.

We were missing sig logs for some oxycontins, Opanas, and Zomigs.

And one in particular caused me to call the auditors and ask them what they were thinking:

The script was:

Marinol 5mg 1 bid #60 1 refill
phoned in rx.

According to the auditors, they claim that Florida law prohibits the filling of CIII prescriptions for more than 30 days. They are trying to rescind payment on the refill claiming that Florida Law prohibits refills on phoned in CIII. Here is the Florida Statute:

http://www.myfloridahouse.gov/FileStores/Web/Statutes/FS09/CH0893/Section_0893.04.HTM

read paragraph 7 (g) and paragraph 7 (2(e))

I argued with the auditor that the law says nothing about refills. It merely says I may not dispense more than a 30 day supply. I told him this all depended on how you interpreted the law and you cannot punish us for interpreting the law differently than their firm. Then I found this online:

http://www.doh.state.fl.us/mqa/declaratory/pharmacy/info_Declaratory_Statement.pdf

The auditing firm stated that any documentation i wish to submitt they would consider. Who do these people think they are? We are gonna fight this all the way. Talk about abuse. Their business is dependent upon technicalities and not Fraud.

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[297point1]

I suspect there is little that you can do for the other scripts, but give them hell for the Marinol.

 

[PharmDstudent]

That's why I'm glad we're not in-network with Express Scripts anymore. Our auditor was a former employee which made it really awful.

 

[pezdispenser]

Yep, I'm in FL too and I have that CIII thing in my file. Tell 'em to read it and weep

 

[Doctor M]

Yep, I'm in FL too and I have that CIII thing in my file. Tell 'em to read it and weep

They are wrong on the Marinol. As for the other scripts, we have obtained patient affidavits that they indeed pick up the prescriptions and we also got physician affidavits for the other prescriptions. The Marinol rx pissed me off. I argued with the auditor on the phone for a long time. We will lose at like 5K at least.

 

[Farmercyst]

They are wrong on the Marinol. As for the other scripts, we have obtained patient affidavits that they indeed pick up the prescriptions and we also got physician affidavits for the other prescriptions. The Marinol rx pissed me off. I argued with the auditor on the phone for a long time. We will lose at like 5K at least.

We had to do affidavits as well on a wellcare audit. Brand Aricept, Humira and afew other choice drugs.

 

[awval999]

They are wrong on the Marinol. As for the other scripts, we have obtained patient affidavits that they indeed pick up the prescriptions and we also got physician affidavits for the other prescriptions. The Marinol rx pissed me off. I argued with the auditor on the phone for a long time. We will lose at like 5K at least.

Once you have the affidavits are you golden?

 

[Doctor M]

Once you have the affidavits are you golden?

I dont think you can ever be Golden with These audits. You are at their mercy pretty much.

 

[Doctor M]

http://www.shands.org/professionals/drugInfo/bulletins/0109.pdf

I am submitting the Declatory statement from the board and the above link as proof that refills on phoned in control III's are allowable. The auditor had the audicity to tell me that the stricter law applied in this case, even though the law is ambiguous.

 

[lorain]

As some1 in the business, I just want to tell you folks get used to it

Payors are doing this more and more

and from what I know, there are 3rd party companies who do the audits and give you a estimate to payor how much they will get back, and then they take a certain percentage of it

its a joke, but its reality

 

[Doctor M]

As some1 in the business, I just want to tell you folks get used to it

Payors are doing this more and more

and from what I know, there are 3rd party companies who do the audits and give you a estimate to payor how much they will get back, and then they take a certain percentage of it

its a joke, but its reality

it is a sick reality.

 

[southpharmindy]

We got chargebacks for a grand total of 10k last year on an audit. I went through an audit assistance company called PAAS international and we were able to cut it down to 3k. Might be worth your while to check them out.

 

[owlegrad]

It is such big business that we have audit assistance companies? I had no idea.

 

[jasonkido]

Question: How far back can they audit for chargebacks. I've worked at my long term care pharmacy for a 18 months and so far no audits.

 

[MountainPharmD]

As some1 in the business, I just want to tell you folks get used to it

Payors are doing this more and more

and from what I know, there are 3rd party companies who do the audits and give you a estimate to payor how much they will get back, and then they take a certain percentage of it

its a joke, but its reality

This is correct. Its a third party company that hires contract technicians to do the audits. Yes, the PBM requested the audit but look who is conducting it. Contract technician jobs with no benefits doesn't attract the best and brightest.

 

[lorain]

this is how I know it happens @ payor:

these 3rd party #s looked at the claims data, gave a rough estimate of how much they could get back (minus their percentage on that rough estimate)

when the manager in charge sees that potential $ coming back, they will JUMP on it

I totally disagree with it (obviously they should audit for the major things, but not the ticky tack things)

 

[lorain]

my advice to every1 in the pharmacy is to cross all your dots and cover yourself

audits will only increase going forward

when you have ridicolous drug prices, payors will look to recoup $ back somehow

 

[Ackj]

Question: How far back can they audit for chargebacks. I've worked at my long term care pharmacy for a 18 months and so far no audits.

I'm not sure about a full audit, but a few months ago we received a notice that they wanted to see a copy of a few rx from Oct-Nov 09. We had to crawl through some rafters to find it all, but we eventually found it. So that's about 24 months there. Granted these were a few specific rx they requested, not an entire range, although maybe they screened the range and these few were just flagged.

 

[southpharmindy]

Absolutely it is bad enough to get audit assistance.

Here are some numbers off the top of my head: 4.44 for a month of Metformin, 1.33 for a month supply of lisinopril, 42.00 for a Proair inhaler that I paid 38 dollars for.

Now the third party comes back and hits you with 30k dollars worth of chargebacks which are "random" and just so happen to be for high dollar drugs like Procrit or Humira. And the chargebacks in no way involve fraud or abuse; the patient got the drug but a minor bookkeeping error that you had never heard of happened.

This is what we are facing.

 

[PharmDstudent]

it is a sick reality.

I got a pharmacy news letter from the BOP today, and in it, it says "Some insurance auditors have attempted to interpret "written" form as handwritten. When the Board has required something to be "handwritten" it has specified that method of recording." So obviously...

... and keep up the good fight against those deceptive auditors!