PBM Prescription Validation Requests Rose 123% in 2023 – What You Need to Know
PAAS National® saw the number of validation requests/concurrent claim reviews more than double in 2023! OptumRx®, who conducts the majority of these reviews, discusses the Prescription Validation Request (PVR) in their pharmacy manual as follows:
Administrator conducts limited scope prescription validation reviews for quality assurance purposes (“PVRs”), which are distinct from and are not considered audits. PVRs are utilized to verify the accuracy and validity of prescription claim submissions. Claims are monitored daily for appropriateness and potential billing errors and selected for review prior to payment. Network Pharmacy Providers are typically contacted via fax or email and asked to provide photocopies of specific documents and records related to its claims submitted to Administrator.
While they want to skirt audit laws by not calling them an audit, make no mistake – they are audits, and payment is at stake! Besides OptumRx®, we also see claim reviews from Caremark®, Express Scripts®, Humana®, MagellanRx, MedImpact and Prime Therapeutics. Below you can see the top 5 drugs reviewed in 2023 and the top 5 concerns after reviewing each claim.
Top 5 drugs reviewed in 2023:
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- Lantus®
- Humalog®
- Creon®
- Levemir®
- Invega®
The top 5 concerns:
- Black out acquisition cost and/or profit margin values on the backtag
- Document the reason for the cut quantity – auditor will want to know why the pharmacy dispensed less than what was prescribed
- A clinical notation is needed and requires 4 elements: Date, who you spoke with and their title, what they confirmed and the pharmacy employee initials
- No backtag/sticker attached, typically requested by the PBM and also helpful for PAAS in order to review the billing elements
- Verify the quantity prescribed and make a clinical notation on the hard copy – Unit of Measure (UOM) is not specified or doesn’t make sense for the medication ordered
PAAS Tips:
- Use our Self-Audit Mindset tool found under the Proactive Tips tab to review your prescriptions prior to sending to PAAS
- Be sure to include a backtag or screenshot for a PAAS analyst to review the billing elements
- Review and utilize our Days’ Supply Charts found on the PAAS Member Portal:
- Share and review the following Newsline articles with your staff in relation to the top drugs reviewed and common concerns listed above
- September 2022, Prescription Quantity Changes Require Documentation
- June 2023, Audit Target – Pre-Filled Injectable Pens and Syringes
- July 2023, Seeing Too Many or Repeated Prescription Validation Requests – Take Action!
- December 2023, Avoid the Creon Chargeback Catastrophe by Following THIS Billing Rule
- December 2023, Insufficient/Missing Clinical Notes Yield Audit Recoupments
- Keep in mind that while these requests can be a nuance and disruption to your workflow, they can be to your advantage. In the long run, they provide more immediate educational feedback to pharmacy staff and help by allowing pharmacies to fix billing errors that may otherwise go undetected and have backend risk of audit recoupments on all refills.
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
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