In recent years, the auditing process has evolved into a full-blown investigation, often requiring pharmacies to submit hundreds of pages of documentation
Compliance audits launched by pharmacy benefit managers (PBMs) have long been a cause of frustration for pharmacies, especially independent community pharmacies with limited manpower and resources compared to large chains. This challenge has only magnified since the onset of the COVID-19 pandemic in early 2020.
PBMs have adapted their practices by switching to virtual audits, leaving them with the ability to review more claims than ever before. As a result, pharmacies that are juggling the chaos of audit documentation, vaccine distribution, prescription refills, and a plethora of other responsibilities stand to lose. It’s no wonder that the average audit in 2020 cost pharmacies $23,978, which is 35% more than the annual average over the previous 5 years, according to the pharmacy audit assistance service, PAAS National.
Traditionally, a PBM would simply check that the pharmacy received a valid prescription, dispensed the proper amount according to the prescription, and submitted a claim for the correct amount dispensed. But in recent years, the auditing process has evolved into a full-blown investigation, often requiring pharmacies to submit hundreds of pages of documentation—and auditors can even use minor clerical errors as excuses to deny payments.
As pharmacy compliance audits grow in sophistication, it’s up to pharmacies to remain diligent in monitoring their operations, especially the following aspects of their operations in 2022. Here are some tips for getting ahead of and managing audits in the year ahead.
PAAS National observed a 40% uptick in the number of prescriptions reviewed by PBMs in 2020. This datapoint reinforces the need for pharmacies to establish a thorough self-auditing process that ensures at least 2 sets of eyes on every order.
For example, the pharmacy technician who runs an order through can look over the details of a set of prescriptions first, and then a second designated person can review them a second time. This process should be conducted weekly or even daily, especially in the case of high-dollar and common discrepancy prescriptions, such as insulin, topicals and inhalers.
Pharmacies should discuss billing procedures for these items to ensure that staff understand how to correctly submit claims for them and provide job aids where necessary to prevent common quantity or days’ supply miscalculations.
Shortly after the pandemic began, PBMs opened edits on refills, meaning that no prescription, or at least no maintenance prescription, would reject due to refill too soon or quantity requested.
This measure was implemented to provide pharmacies and patients additional convenience around refilling medications when stay-at-home orders and social distancing limited pick-up opportunities. While this amendment makes refilling prescriptions easier, the pharmacy must be aware of the fine print, and how it may be subject to audit.
PBMs will often compare the number of times a prescription has been refilled with the number of refills approved by a physician to make sure that the numbers match. The lifting of refill edits does not imply that pharmacies can add refills without contacting the prescribing physician for permission first.
As best practice, pharmacy staff should thoroughly document early refills with a hard copy and handwritten notes specifying an early refill due to COVID-19, as benefit managers don’t check the pharmacy’s computer system when conducting prescription audits.
3. Chart Notes
Auditors have turned their focus to chart notes in recent years, especially chart notes for high-cost drugs, such as dermatology medications or topicals. A PBM will want proof that a patient has been seen in the past month.
In the case of a maintenance prescription, there needs to be documented proof of the patient’s relationship with that physician, as well as a diagnosis. Pharmacies understand the importance of documenting patient-physician relationships; however, there are scenarios that make this difficult.
For example, a pharmacy may communicate with a physician to have them prescribe a certain drug repeatedly and when the audit notice arrives, the physician refuses to share the chart notes with the pharmacy for documentation.
For any medication, but especially high-cost drugs, pharmacists should make sure that they are in constant communication with the prescribing physician to confirm that a relationship with the patient exists.
When launching an audit, a PBM will likely request thorough documentation of a pharmacy’s purchases from their wholesalers to ensure that those amounts match with the amounts in the claims submitted to the insurance company. As a standard practice, pharmacies should stress to staff the importance of adhering to the exact National Drug Codes (NDC) on each item and ensure that they are purchasing and submitting the same 10-digit code.
A common mistake is submitting the wrong quantity of the same medication, because just the last 2 numbers in the NDC are different. If a pharmacy submits the NDC for drug in a pack of 100 when a 50-pack was purchased, a PBM will take the back as inventory shortage, even if that drug on the pharmacy’s shelf in a different quantity.
Tracie Acosta, CPhT is a Manager of Provider Network Quality Compliance at the Elevate Provider Network, AmerisourceBergen’s pharmacy services administrative organization (PSAO). Tracie has over 12 years of experience in the pharmacy industry, including retail Pharmacy operations and PBM audit management and operations