Types of Audits Your Pharmacy Could Face

 Posted on September 15, 2018 in PBM Pharmacy Audits

Audits to your pharmacy can be made by insurance companies, pharmacy benefit managers and third-party payers. Many pharmacy owners view audits as a threat to their business and with good reason.

The outcome of an audit can mean that a pharmacy is required to pay large sums of money that the auditing agency says it is owed. This could be taken out of what would be payments from future money that would be paid to the pharmacy.

Audits should be taken seriously, and often an attorney can safeguard a pharmacy’s rights as well as negotiate issues that may come up in the course of an audit.

There are six types of pharmacy audits:

1. On-site/field audit. This type of audit is done at the pharmacy so that its operations can be thoroughly reviewed. Typically, this type of audit is announced ahead of time and a pharmacy will be given a list of prescriptions that may come up in the audit. However, this is not always the case. Though uncommon, on-site audits performed by Medicaid can be made without warning ahead of time. On-site audits usually cover claims for the prior 12 to 18 months.
2. Purchase verification. These audits are made pursuant to third-party payer agreements. This audit consists of an investigation of the amounts and national drug code (NDC) of pharmaceuticals that are submitted by pharmacies from wholesale receipts.
3. Investigational audit. Investigational audits are usually smaller in scale and done via phone and/or mail. Pharmacies will be asked to submit copies of certain documentation of claims paid during a timeframe. Prescriptions, signature logs, electronic records, and invoices are all commonly requested. An auditor could be concerned with the amount of medications ordered versus the amount dispensed, or the audit may be about something more serious such as fraud.
4. Desk/mail audit. In this review, the auditor will use automated means to detect patterns with respect to issues such as prescribing, overrides, ingredient cost and billing. The audit will look for system abuse or fraud.
5. Prescriber and member audits. Prescriber audits examine one claim and seek verification with the prescribing doctor that each party’s records agree. Member audits only differ in that the claim is verified with the patient.
6. Telephone audit. This type of audit is used when a single claim or small amount of claims are incorrect and discovered by the pharmacy benefit manager (PBM). The pharmacy will be asked to correct the claim billing, and if it does not, the PBM will often reverse the claim. A PBM may also decide to conduct a larger audit.

Contact an Illinois Pharmacy Audit Attorney

The outcome of an audit can be devastating to your pharmacy. Hiring a skilled Illinois pharmacy audit lawyer will ensure that an auditor follows the contracts in place and other binding procedures. Call our firm at 630-310-1267 to arrange for your first meeting.

Source:

https://www.aprx.org/issues-advocacy/payment-audits