June 22, 2021
Hoping that your community pharmacy won’t be audited is not a good business practice. If you fail to meet expectations, there’s a possibility that pharmacy benefit managers could cancel your contract. Then, you’re not just facing financial challenges, you’ve lost all access to your patients. They can also stop reimbursements from Medicare and Medicaid and they will let other PBMs know that you’re in violation.
Avoid major pitfalls if your pharmacy is audited by watching out for these eight common audit discrepancies.
Maintaining accurate prescription records is critical to your business — especially if your pharmacy is the target of an audit. Pharmacies must maintain the hard copies of prescription records that patients bring in for up to five years after the prescription is dispensed depending on state and federal laws, or if the pharmacy is involved in an ongoing audit or investigation.
A good routine business practice is to file a prescription’s hard copy immediately once the prescription is dispensed so it doesn’t get lost or forgotten.
Also, some state laws require that call-in or faxed prescriptions be reduced to hard copy form with specific details such as that the hard copy must be signed and dated in ink. Know your pharmacy’s state laws and train your staff in the proper methods to maintain hard copies
Your pharmacy knows that refills must be clearly indicated by the prescriber, but just as important is maintaining documentation of prescription refills. Know your state and federal laws when it comes to refill orders called in by phone or faxed to your pharmacy.
Without refill documentation, your pharmacy could be subject to a discrepant claim. One of the common violations is filling a prescription more times than the prescriber authorized.
You can also get into trouble for refilling a prescription too soon, so when you do have to refill a prescription sooner than appropriate, be sure to document why. For example, the prescription was lost or stolen or there was a change in directions for the prescription.
Your pharmacy must submit the quantity and days supply of a prescription based on the amount issued by the prescriber. If you issue a prescription greater than the documented days supply, you could face a chargeback.
Here are the top drugs that get caught up in audits because of incorrect days supply, according to PAAS National:
4. Eye drops
Your pharmacy must maintain the correct dispense as written (DAW) codes according to the set NCPDP standards or the prescription claim could be labeled as a discrepant claim and go unpaid.
DAW codes clarify prescriber instructions about substitutions for the payer. So, if a drug isn’t available, your pharmacy uses a DAW code to tell the payer why you dispensed a prescription the way you did.
If you use the wrong DAW code, you may get reimbursed at the wrong rate or not get paid at all.
Using the wrong DAW code can trigger an audit, especially if you don’t have enough documentation to justify why you used the DAW code that you did. PBMs will use that as an excuse to take back money from your pharmacy.
Make it standard procedure in your pharmacy to double-check that the correct DAW code is used based on the information on the prescription and the prescriber’s signature.
Make sure to always include calculable, specific directions on every prescription dispensed based on the quantity issued by the prescriber.
A “use as directed” prescription may be considered valid if the prescriber indicated a certain quantity and days supply within clinical reason.
Also keep in mind that Medicare Part D rules and regulations are different for keeping records and filling prescriptions. Check the Centers for Medicare and Medicaid Services for audit information.
You can get dinged in an audit for dispensing any prescription incorrectly, but PBMs have recently begun to zero in on controlled substances like opioids. Because of this, it’s crucial for you to be aware of the federal requirements for dispensing controlled substances.
When you dispense a prescription of a controlled substance, you need to include all this information for the prescription to be considered valid:
It’s not only the PBMs that will get you if you make errors with controlled substances. The DEA will also inspect your pharmacy and check for DEA Form 222s, and every error you make can result in a fine of $14,000.
One little digit can cause a lot of hassle, so make sure that you always enter the correct prescription origin code when you dispense medication.
These codes signal how the prescription was received by the pharmacy, and break down like this:
If you enter the wrong prescription codes, some PBMs will take back the entire cost of the drug, while others will take back a certain amount every time a prescription is refilled. If a prescription is refilled 12 times with the wrong origin code, that can add up.
For every prescription you dispense, you must obtain a signature. If you don’t keep good records of those signatures, you could face consequences from your PBM.
While many PBMs relaxed their signature log requirements during the coronavirus pandemic, be prepared for when those relaxed requirements go away so you don’t get caught off-guard in a future audit.
PBA Health is dedicated to helping independent pharmacies reach their full potential on the buy side of their business. The member-owned company serves independent pharmacies with group purchasing services, expert contract negotiations, proprietary purchasing tools, distribution services, and more.
An HDA member, PBA Health operates its own NABP-accredited warehouse with more than 6,000 SKUs, including brands, generics, narcotics CII-CV, cold-storage products, and over-the-counter (OTC) products.
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