Pharmacies are learning expensive lessons with insurance audits.
More pharmacies will be audited by insurance companies...and denied thousands of dollars in reimbursements due to prescription errors.
Consider these strategies to help avoid hefty penalties.
Reinforce with your techs the importance of double-checking days' supply, quantities, dosage forms, and DAW codes.
Tell them to stay especially alert for frequently audited meds, such as insulin...inhalers...eye or ear drops...topicals...blood glucose testing supplies...and specialty meds.
Continue to clarify "use as directed" sigs...and document any important details on the hard copy Rx and in your computer.
Know your state laws for specific prescription requirements. Insurance companies will also use these to guide reimbursements.
For example, some states or payers mandate diagnosis codes on Rxs. Pharmacies can lose reimbursements and be fined by inspectors if Rxs are missing these details.
Work with your team to make sure you have up-to-date fridge and freezer logs, signature logs, policy and procedure manuals, etc. These may be checked by an auditor...as well as your state board inspector.
Gather requested information during an audit...such as hard copy Rxs and signature logs. Answer questions honestly and don't guess.
Don't panic if the auditor finds something amiss. Payers will usually give your pharmacy 30 days for appeals...and allow you to correct some findings for a partial or full reimbursement.
Get our new cheat sheet, Tips to Help Prevent and Survive a Pharmacy Insurance Audit, for more on how to handle audits.
- J Manag Care Spec Pharm 1999;5(2):93-8
- www.amcp.org/audit/
MINSU LU March 6, 2020
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