Has anyone been through a pharmacy audit?

[crossurfingers]

This question is especially for retail pharmacists. What generally happens? I know for sure they would check up on the Medicaid prescriptions. How do they go about it- for example do they just pick a box of rx's that you have in back storage or does there have to be a case that they are specifically investigating? Another example- would they just pick random C2's and check if you filled them correctly? And say there wasn't a patient's address on the front of it or there was more than one C2 listed on the same rx (technically illegal in our state)- would the pharmacy be fined? Would they go after the pharmacist? Do they only concentrate on more major issues?

I've been reading up on my law notes and noticed how many laws we "bend" in retail pharmacy. Re-reading the auditing and record keeping procedures is kind of freaking me out. They could get you for something you did years ago!

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[Megas]

I've only been through 2 audits, as a student on rotation-they suck! They were both commenced by Medco auditors, both around Christmas. Medco auditors only go after prescriptions covered by Medco. The state supplemental insurance for PA (PACE) only looks at rxs covered by PACE. Basically, the pharmacists spent hours going through prescriptions that fit the "$100 rule", if the rx was for over $100, the auditor would scrutinize it, cause they got a % of the money they recovered. If the prescription was for over $250, it had better be perfect. If it was for over $1000, they would find something wrong with it (especially if left alone with it). Check every rx, make sure it's perfect, put it back in the california files, then pile them on a table/desk for the auditor as randomly as possible for as short a period as possible. Never leave an auditor alone with anything, never allow them access to the computers, never trust them. I knew one small independent who videotaped them. Auditors are there to find mistakes, try to make up mistakes if the rx is for a lot of money, and make money. It's not about the patient, or concern for the law, whether it was a CII didn't matter unless it was an expensive CII. They ignored cheap rxs. It's just about money-the whole thing was a mind****. I've never been through a DEA inspection though. If you are a chain, your audits are usually your PDM's problem, if you are a small independent, there are audit advocacy organizations that can help prepare (http://www.paasnational.com/).
No, they didn't go after the pharmacist, just the money.

 

[tussionex]

i went through one, many years ago, when i still worked retail. i was in my fifth year at ACP, and as the up-and-coming intern, it was my job to babysit the auditor all day, make copies, do whatever.

so, the auditor shows up, and the tech that brings him back is all creeped out (we all knew the audit was happening). i look at this guy, and he happens to be an old friend, a pharmacist i had worked with a few years prior!

so, i spend the day hanging with my buddy, he picked through his required records (they really only care about the $$), and then we hung out the rest of the day. ok, so my store got lucky, i guess.

my point? be nice to your fellow pharmacists - we tend to be a very close knit profession and you never know when a former co-worker will come to your rescue!
the guy in the story passed away last year, i miss him.

 

[Megas]

That sounds warm and fuzzy, how long ago was it? Are you just a very nice person? The audits I saw this past year were ruthless.

 

[rxlynn]

I participated in one a couple of years ago - I think it was Express Scripts. They faxed a list of specific Rx numbers that they wanted to review before the audit (maybe about 5 days before). We pulled out those california files, and then when the auditor actually came, I stood by her and pulled the specific Rx of interest out of the books and handed it to her. She was very insistent that she didn't want to see anything else in the book or computer because of Hipaa issues. She would take the hard copy, and then had some sort of software program in her computer that she would enter specific info. about the Rx. Then, in about a week or so, they sent a letter to the DM that specified the problems they had found and what money they wanted back. Then, the DM had a certain amount of time to respond if they wanted to dispute anything.

It seemed like a lot of what they were looking for was days supply, and UAD when applied to glucose test strips or other meds. It can really be an insurance problem when docs write UAD on Rxs.

 

[tussionex]

That sounds warm and fuzzy, how long ago was it? Are you just a very nice person? The audits I saw this past year were ruthless.

i dont suppose im a terribly nice person, just search for some of my other posts.

yes, it was way more warm and fuzzy than any other audit. ever.
it was about 7 years ago.

 

[Megas]

From the other audit discussions, it must be me--I'm just bad to have at audits! If I am at the pharmacy when you are audited, it's going to suck. You will be audited by Satan and lose thousands of dollars. If I'm not there, you will be audited by Clark Kent, get a friendly follow-up letter and possibly go out for drinks afterwards.