Audit Risk: Prescriber Scope of Practice and Treating Self or Family
Everyone knows that PBMs do not perform “random” audits, nor do they select “random” claims in these audits.
Entries by Eric Hartkopf, PharmD
2024 National Health Care Fraud Takedown
On June 27th the U.S. Department of Justice (DOJ) issued a press release outlining a National Health Care Fraud Enforcement Action that resulted in 193 defendants charged, including doctors, nurses and pharmacists, and over $2.75 billion in false claims.
Diabetic Test Strip Authorized Distributors
Independent pharmacies continue to receive threatening letters from LifeScan and an affiliated law firm on a monthly basis.
How to Safeguard Your Pharmacy from Fraudulent Electronic Prescriptions
PAAS National® has recently assisted pharmacies who received fraudulent electronic prescriptions from prescribers that had their electronic prescribing credentials hacked or stolen.
Commercial Claims Reimbursed through Embedded GoodRx® Discount Cards
Pharmacies have been reaching out to PAAS National® with concerns about claims being reimbursed through an embedded discount card (e.g., GoodRx®) rather than a patient’s commercial insurance plan benefit.
OptumRx Auditing for Medical Supplies Billed Under Medicare Part D
In March 2024, PAAS National® analyst assisted nearly 100 pharmacies with desk audits from OptumRx requesting documentation related to claims for medical supplies (primarily alcohol swabs) that were processed by OptumRx under the Medicare Part D benefit.
V-Go® All-In-One Insulin Delivery Patch
The V-Go® all-in-one insulin delivery patch is a disposable device approved for use in patients with Type 2 diabetes.
Caremark Notice of Breach – Aberrant Practices and Trends
PAAS National® analysts have recently assisted multiple pharmacies that received faxed notifications from Caremark that their pharmacy has “breached” the PBM Agreement by exceeding an arbitrary 25% threshold (by $ or # of claims) on the Aberrant Product List for their total claims dispensed in January 2024.
Caremark Invoice Audits – Purchases from Other Pharmacies
Caremark invoice audits continue to plague many pharmacies and often result in substantial audit findings and, occasionally, network termination.
Qualified Medicare Beneficiary (QMB) Program
Pharmacies may bill prescriptions from time to time for patients with dual eligibility, possessing both Medicare and Medicaid benefits.
