In case of compliance audits by pharmacy benefit managers, also known as PBMS, you, as a pharmacy owner, ought to watch out for dosage and financial calculations on prescriptions, the number of drug refills, the accuracy and timeliness of patient chart notes and any excesses or shortages in inventory. Why? The aforementioned four form the criteria for which PBMs will audit your pharmacy and the investigational process has become longer and more drawn-out than before in recent years.
While essential, compliance audits have always posed a challenge for pharmacies, particularly independent community ones short on staff and resources when compared with bigger chains. This hardship has only grown since the start of the pandemic in March 2020. PBMS have adjusted with the times by changing from in-person compliance audits to virtual ones, making it possible for them to evaluate more claims than before. The procedure is harder as your pharmacy keeps up with audit paperwork, the dispensing of vaccines, drug refills and other compliance-related duties. As a result, audits may cost you nearly $25,000; which the pharmacy audit assistance services, PAAS National, states is almost 40 percent more than the yearly average in the past five years.
In the past, during an audit, a PBM would inspect a pharmacy’s records for legitimate drug prescriptions and insurance claims with the right dosage and financial amounts. However, overtime, the audit has emerged into a full-scale probe, requiring your pharmacy to turn over hundreds of pages of material with mere mistakes as grounds for denying reimbursements.
To counter these challenges, you can start by maintaining an internal self-audit of prescriptions. You could charge your team of pharmacy technicians to review the details of the prescriptions on a daily and weekly basis to make sure they are error-free, especially for the most expensive medicines. You might also want to retrain your staff on proper billing practices and claim submissions. Secondly, you may want to keep an eye on your pharmacy’s refills to ensure they don’t occur too soon or the dosage or quantity amounts are not excessive.
The process for refills has changed since the onset of the pandemic to make home for patients staying home during lockdowns and social distancing periods. This means more mail delivery of refills and accompanying documentation. You should maintain thorough physical-copy records of early refills and handwritten notes because PBMS do not inspect computer systems for their audits. Thirdly, you ought to file substantial evidence of physician-patient visits and interactions, especially chart notes, especially for costly drugs.
As a pharmacy owner, you are all too well aware of the importance of proving doctor-patient relationships. However, it may be difficult for you to cooperate with a PBM during an audit if, for instance, a physician will not share chart notes with your pharmacy to protect patient privacy. Fourthly and lastly, you must track your inventory for compliance with the National Drug Codes, which dictate your drug and other resource purchases. Errors can occur with the wrong quantities of the same drug all because of a difference in codes. PBMS will also find shortages or excesses in your inventory based on such mistakes.
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