NCPA Commends Congressional Concern Over Abusive Pharmacy Auditing Practices



ALEXANDRIA, Va. (Nov. 19, 2013) — In serving Medicare seniors, community pharmacies should be subject to the same three-year audit review period as hospitals and not forced to document 10-year-old claims.

That is the message two members of Congress are delivering to their colleagues on Capitol Hill, with the support of the National Community Pharmacists Association (NCPA). U.S. Reps. Doug Collins (R-Ga.) and Martha Roby (R-Ala.) each sent letters articulating their concerns to the leaders of the House Energy and Commerce Committee and Ways and Means Committee.

“Patients rely on their independent community pharmacists to ensure proper medication use, to guard against drug interactions and to help take advantage of lower-cost generic drugs, where appropriate,” said NCPA CEO B. Douglas Hoey, RPh, MBA. “These pharmacists should not face needless distractions to patient care such as documenting why they filled a prescription a decade ago. We appreciate Reps. Collins and Roby taking the time to not only meet with some of the pharmacy small business owners that they represent, but for also registering their concern with the appropriate committee leaders.”

Rep. Collins wrote, “A few weeks ago I was back in my district and had the opportunity to visit with several small pharmacy owners and their employees about issues they face and deal with every day. It was very concerning for me to hear the struggles and lack of leverage these constituents face when conducting business with large pharmacy benefit managers.”

He added, “If there are bad actors in pharmacy they should certainly be audited, but why should the PBM need ten years to being an audit to uncover fraudulent activity? Precedent for a shorter look back already exists within the Medicare [recovery audit contractor or RAC] process. This process allows for a hospital to be audited three years from the date a claim was paid. I believe a shorter look back period should also apply to audits of pharmacies.”

“[O]ne could question why PBMs need ten years to begin an audit,” Rep. Roby wrote. “Precedent for a shorter look back already exists within the Medicare RAC process.” She also urged the committees to examine PBM auditing methods, a shorter look back period and what percentage of funds recouped from pharmacies by auditors are actually returned to the Medicare trust fund. In addition, Rep. Roby expressed concern that “pharmacies are frequently reimbursed below their cost to dispense drugs” and that PBM payment benchmarks for generic drugs are not updated frequently enough to avoid “artificially decreasing pharmacy drug reimbursements.”

“When a community pharmacist fills a prescription at the right time, for the right patient and for the right price, it should not be a punishable offense,” Hoey added. “Pharmacists support reasonable oversight to guard against fraud. But far too often pharmacy audits have deteriorated into fishing expeditions intended to line the pockets of middlemen at the expense of health care providers over minor clerical discrepancies.”

Twenty-nine states have enacted legislation setting common-sense standards for pharmacy audits. The Medicare Prescription Drug Program Integrity and Transparency Act (S. 867), introduced by U.S. Senators Mark Pryor (D-Ark.) and Jerry Moran (R-Kan.), would implement similar reforms at the federal level, ensure that legitimately recouped funds are passed through to the plan sponsor (such as Medicare) and ban 10-year-old audits.

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