UPDATE: What Is a Pharmacy Audit?

 Posted on September 26, 2023 in Pharmacy License Defense

Originally published: January 16, 2018 -- Updated: September 25, 2023

Update: As described below, there are several types of audits that may be performed by pharmacy benefit managers (PBMs), and these audits may review a wide variety of records to address prescriptions that have been filled and payments pharmacies have received from insurance companies. In recent years, virtual audits have become more common, and in these cases, auditors may require pharmacy personnel to provide a wide variety of documents and other information.

If an audit identifies any discrepancies related to prescription records, purchases of drugs, or claims submitted to insurance companies, insurance companies may claim that a pharmacy received improper payments, and they may seek to recoup these amounts. This may be done by requesting monetary payments from a pharmacy or withholding future payments for services provided to patients.

In many cases, discrepancies may be resolved by providing the necessary documentation. However, this can be very time-consuming, and specific time limits may apply for submitting the required information. Understanding the process of appealing the findings of an audit is not always easy, and pharmacy owners may be concerned that if they do not respond to an audit correctly, they could not only be required to pay financial penalties, but they could face termination from a pharmacy network. Audit results reported to government agencies could also lead to other legal concerns, such as potential investigations by the DEA based on concerns about a pharmacy’s handling of controlled substances.

Because of the legal and financial concerns that may affect pharmacies that are audited, it is important to work with an attorney in these situations. At The Law Offices of Joseph J. Bogdan, Inc., our Illinois PBM pharmacy audit lawyer can provide assistance when preparing for audits, responding to requests from auditors, and addressing the findings of an audit. In addition to making sure pharmacies meet all requirements during an audit, we can help determine whether litigation may be necessary to address financial penalties or prevent network termination. To learn more about how we can help with issues related to audits, contact us at 630-310-1267 and arrange a free consultation.

The process to become a licensed pharmacist takes much time and effort, and to own a pharmacy comes with more expectations and requirements. If you own a pharmacy, you may expect to have pharmacy compliance audits run from time to time. There are many factors in pharmacy audits that you need to know in order to meet guidelines to keep the pharmacy intact.

Definition of Pharmacy Audit

A pharmacy audit is a formal review of operations and processes to make sure that pharmacies are compliant with pharmacy regulations and other related agreements. The pharmacy audit process can come in many different types, including desktop, onsite, prepay claims review, and investigational pharmacy audits.

• Desktop pharmacy audits are done in-house on claims that have been adjudicated, also known as Documentation and Verification Audits (D&V).
• Onsite pharmacy audits occur when an auditor reviews adjudicated claims against a prescription onsite at the pharmacy, and policies and procedures will be thoroughly reviewed with an interview with a senior pharmacist. A report will be completed, outlining any discrepancies regarding the pharmacy.
• Prepay claims review pharmacy audits occur when adjudicated claims are audited before a payment is made, with the objective to identify claims with dosage and payment discrepancies and resolve them before payment. Unlike other types of pharmacy audits, claims are not adjusted, reversed, or stopped at a point of sale.
• Investigational pharmacy audits are more extensive than a desktop or onsite pharmacy audit. Depending on the situation of a discrepancy being researched, the complexity of the investigational pharmacy audit process may vary.

Onsite pharmacy audits typically take no more than 60 days to close, depending on the circumstances and outlying discrepancies. Desktop audits, however, usually take around 90 days to close, again depending on the given circumstances.

If pharmacies do not comply with regulations in the auditing process, they may face a penalty fee, corrective action to be taken, or even suspension.

Call a DuPage County Pharmacy Audit Lawyer

It is very important to know what to expect in a pharmacy compliance audit. At The Law Offices of Joseph J. Bogdan, Inc., we have over 17 years of knowledge and experience in pharmacy license law. Attorney Joseph J. Bogdan is also a registered pharmacist, so he thoroughly understands pharmacy audits and how they work. To schedule a free consultation, please call a Lisle IL pharmacy license attorney at 630-310-1267 for effective legal representation.