PBMs routinely conduct audits, whether it be on-site or desk-top audits, on the member pharmacies. By and through such audits, PBMs are supposed to monitor pharmacies’performance and to capture improper payments made to the pharmacies. However, PBMs often go beyond the intent of the audit and utilize audit as a source of revenue for themselves at the expense of independent pharmacies, plan sponsor, taxpayers, and most importantly, patients. PBMs clawback the entire amount of reimbursement on claims that were already dispensed by pharmacies. This not only causes significant financial harm, but also disrupts the pharmacy’s day-to-day business.
Analyze Dispensing Data – Protect your business
Pharmacy benefit managers (PBMs) have access to your store’s prescription claims data and can identify claims that don’t meet legal, regulatory, industry or PBM-established standards. Under such scrutiny, independent pharmacies most commonly fall short with claims submissions in the following five areas:
Federal and state requirements determine what constitutes a valid prescription. A prescription would be invalidated if it were missing any legal requirements, such as the prescriber’s signature, drug quantity or date, or if the patient is misidentified.
Incorrect days’ supply
It’s sometimes tough to calculate days’ supply, especially if the prescription calls for dispensing a kit or a complex/atypical dosing regimen. Mistakes commonly occur when entering claims for inhaled, ophthalmic/otic, vaginal and topical products.
Refill too soon
If there is an incorrect days’ supply on a previous fill, it can lead to a prescription being refilled sooner than allowed, which is an immediate red flag.
Days’ supply and number of refills also factor into submitting the correct quantity. For example,a 30-day supply of a maintenance drug with no refills would be incorrect if billed for a quantity of 90. However, that same prescription with three refills would be acceptable for a quantity of 90.
Incorrect DEA/NPI number
The number on the prescription must match the DEA/NPI/prescriber identification number on the claim.
- SmartsRx Audit is here to prepare pharmacies for audits. By combining our deep understanding of pharmacy practice using sophisticated analytical tools, we are able to anticipate problems and highlight them so that pharmacy owners can act upon them before audits happen.
- Claims Data Processing – claim records are continuously collected, analyzed and categorized
- Purchase Records – all purchase records are collected, processed, converted in to reports to identify shortages proactively.
- Reconciliation & Analytics – using our unique coding databases and artificial intelligence tools, we reconcile purchase and claims records and analyze your data to spot inconsistencies and areas of concern
- Results Delivery & Summary – we deliver our findings to decision makers in an easy, relevant report format, highlighting recommendations and areas of concern that make audit preparedness and compliance extremely easy to implement.