Audit Target – Pre-Filled Injectable Pens and Syringes
Pre-filled injectable medication such as insulin, Invega®, Humira®, Enbrel® and Ozempic® remain a big target for audit risk due to their high cost and potential billing pitfalls.
Entries by Jennifer Ottman, CPhT
Post-PHE Claim Submission Requirements for Continuous Glucose Monitors
Now that the PHE has ended and CMS is enforcing clinical indications for CGMs and supplies, pharmacies are left wondering what will happen with continued or refilled claims for CGM related supply items initially provided during the PHE under the waiver/non-enforcement.
Continuous Glucose Monitors and Potential Audit Risk with PHE Ending
As the COVID-19 Public Health Emergency (PHE) declaration comes to an end on May 11, 2023, preparing for some changes to current flexibilities, actions and waivers that have been in place since COVID-19 began is crucial.
Avoiding Humana Audits for Deceased Patients
Humana has recently sent out another round of audits to pharmacies with the subject line: Review of claim(s) billed after member’s deceased date.
A Documentation Checklist for Continuous Glucose Monitor Claims
For any item to be covered by Medicare B, there must be clinical documentation to support the covered diagnosis, prove it is reasonable and necessary for treatment and meet all other Medicare requirements.
Be On the Lookout for Prescription Reversal Requests from Humana
Humana periodically performs retrospective claim reviews. If upon review Humana determines a claim was billed in error (i.e., after the Humana coverage was terminated), the pharmacy will get a prescription reversal letter.
Levemir® FlexPen® is Replacing the Levemir® FlexTouch®
Novo Nordisk® discontinued manufacturing the Levemir® FlexTouch® in early February 2023.
Are Your Delivery/Signature Logs PBM Compliant for 2023?
A common component of a pharmacy audit request is the delivery/signature log.
PBM Prescription Validation Requests Rose Nearly 20% in 2022!
Prescription Validation Requests (also known as claim reviews) are becoming a more frequent occurrence with many PBMs. In 2022, PAAS saw an 18% increase year over year. Some of the reasons these claims get flagged include…
Beware: Caremark is Monitoring High Quantity Utilization and Atypical Dispensing Habits
Beyond traditional desktop, on-site, investigational or invoice audits, Caremark performs various compliance reviews.
