We have our first on site audit! Guess from who!

[Doctor M]

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So today we received a letter from some third party company stating that we are being audited by Amerigroup, with the PBM being no other than....................CVS/Caremark The audit will be an on site audit for claims from 6/10 to 5/11. Since it is Amerigroup, and the time line, im thinking they will be looking at ALF rx's; psychiatric drugs such as Abilify, Seroquel, zyprexa, insulin, and some retail patients. This ought to be fun. They will need hard copies, sig logs and god knows what else. Im bringing coffee and donuts for the auditor. 🙂

 

[Doctor M]

http://nhlgc.org/attachments/coverage/healthtrust/HCR_CVSCaremarkStandardAuditPracticeFINAL.pdf

All you students wanting to open up a store should read this.

 

[Sparda29]

Scumbags. Audits should be outlawed.

 

[Doctor M]

Scumbags. Audits should be outlawed.

ehhh. its ok. im gonna review every claim for amerigroup for high priced items. I will scrutinize every rx i pull, as if i was the auditor. Will take some time, but im not giving that f--king company any money back...🙂

 

[buff100782]

M, make sure you are compliant with all state laws. For example, Rx's in my state must have first and last name of the person calling in the Rx. On a controlled medication, the qty must be written numerically and alphabetically. This law is to prevent pts from tampering rx's. It doesnt make any sense to write this on called in medications, but the PBMs will screw me over anyway they can.

"The same high dollar review is performed for compound medication claims. This review ensures compound claims are paid per the contracted rates and meet the plan design requirements of the plan sponsor." -- This is why I don't accept insurance on compounded claims. You think audits are bad on cause of days supply on insulin and eye drops? Holy ****, they'll put you out of business in a single audit.

P.S. -- Think audits are bad now...how do you think ESI/Medco are going to "save" all this money.

Do we ever get any good news?

 

[Doctor M]

M, make sure you are compliant with all state laws. For example, Rx's in my state must have first and last name of the person calling in the Rx. On a controlled medication, the qty must be written numerically and alphabetically. This law is to prevent pts from tampering rx's. It doesnt make any sense to write this on called in medications, but the PBMs will screw me over anyway they can.

"The same high dollar review is performed for compound medication claims. This review ensures compound claims are paid per the contracted rates and meet the plan design requirements of the plan sponsor." -- This is why I don't accept insurance on compounded claims. You think audits are bad on cause of days supply on insulin and eye drops? Holy ****, they'll put you out of business in a single audit.

P.S. -- Think audits are bad now...how do you think ESI/Medco are going to "save" all this money.

Do we ever get any good news?

I will be reviewing every single high dollar claim for the insurance company in question. I will review the rx, the sig logs, dates written, everything. The insurance company in question is Amerigroup and they dont pay for compounds, so no worries there.

 

[Doctor M]

I wondered why we were picked for an audit, and all i can think is that we fill a lot of psychiatric meds, high dollar ones too. Audits are NOT random.

 

[crazybob]

I wondered why we were picked for an audit, and all i can think is that we fill a lot of psychiatric meds, high dollar ones too. Audits are NOT random.

Don't the anti-retrovirals get audited fairly often? Or maybe it's just some that are several grand.

 

[Doctor M]

Don't the anti-retrovirals get audited fairly often? Or maybe it's just some that are several grand.

They sure do. Im thinking 2 things: Since Amerigroup is a taxpayer funded program, i believe by law they are required to audit pharmacies. Now since we were filling rxs for an ALF but were considered a retail store, im sure it may have thrown some flags up since we filled the same high priced drugs month after month.

 

[owlegrad]

I wondered why we were picked for an audit, and all i can think is that we fill a lot of psychiatric meds, high dollar ones too. Audits are NOT random.

Let us know how it goes. We recently had an audit and I was stunned with the number of holes we had in our prescription records.

I hope it goes well. 👍

 

[Doctor M]

Let us know how it goes. We recently had an audit and I was stunned with the number of holes we had in our prescription records.

I hope it goes well. 👍

I will do! Im really not worried. The only thing i dont like is that its CVS/Caremark as the PBM.

 

[WVUPharm2007]

Just be glad you don't live in the megalopolis...up here we get audited constantly. We had 2 audits in one week the first week of July. One was Tuesday July 5th. The first day back after a weekend extending holiday. They told me it made the day hell. I'm night shift, so I don't have to deal with it...thank god...

 

[Doctor M]

Just be glad you don't live in the megalopolis...up here we get audited constantly. We had 2 audits in one week the first week of July. One was Tuesday July 5th. The first day back after a weekend extending holiday. They told me it made the day hell. I'm night shift, so I don't have to deal with it...thank god...

Ive been through audits before, but this is the first one for an on site audit as an independent. Ive heard horror stories about this. But we will be prepared!

 

[Farmercyst]

Ive been through audits before, but this is the first one for an on site audit as an independent. Ive heard horror stories about this. But we will be prepared!

At least you're organized. Where I interned they were particularly bad. I had to follow up for 3 weeks, getting copies of e-scripts from medical records, pt affidavits for med pick-ups etc because they just didn't have the original records. Saved 23K in chargebacks, but still lost about 3K for reasons beyond our ability to correct.

 

[bacillus1]

If they audit ophthalmics, make sure you enter them as 15 drops/mL, not 20. Caremark audited our store and took back a bunch of money because we use the conventional and widely accepted 20 drops/mL to calculate our days supply.