Caremark
Caremark’s Provider Manual states “notices will be delivered in person by mail, via fax the Provider’s fax number or by email via the email address provided by Provider in Provider’s enrollment documentation or as otherwise indicated by Provider to Caremark and agreed to by Caremark or via Pharmacy Portal.” It goes on to say that it is the responsibility of the provider to notify Caremark when contact information needs to be updated. There can also be times when Caremark will communicate via phone to pharmacies, most commonly seen with desk audits.
OptumRx
OptumRx’s Provider Manual states “Provider understands Administrator relies on the information about its Provider, as well as each Pharmacy location provided by NCPDP and directly to Administrator, therefore, Provider: (1) Agrees to update in a timely manner all information in the NCPDP database whenever … and (2) Immediately notifies ORx and NCPDP of updated contact information at pharmacyprograms@optum.com,including changes in telephone numbers, fax numbers, email address.” In addition, it states OptumRx may communicate via telephone, mail, fax, and/or email when it comes to conducting their audits.
Express Scripts
Express Script’s Provider Manual states “All changes to Provider demographic information for independent Network Providers must be submitted by logging onto https://www.esiprovider.com and completing the online Change of Demographics form. Provider shall also submit updated demographic information directly to NCPDP and/or any other third party website as applicable”. It also states Express Scripts will communicate via fax, email, or USPS when initiating an audit.
Prime Therapeutics
Prime Therapeutics uses the information pharmacies input to their NCPDP profile as their sole means of communication. In the Provider Manual, it states to go directly to the NCPDP’s website https://online.ncpdp.org to submit changes. Prime Therapeutic’s system will incorporate all new NCPDP updates on a weekly basis.
Humana
Humana’s Provider Manual states “[Humana] will notify all pharmacies via traditional mail (UPS or certified mail). If you prefer to be notified via email, we can send letters via secure message. To notify HPSX of your notification preference, please send an email to pharmacyaudit@humana.com.”
Elixir
Elixir also utilizes NCPDP to elicit pharmacy contact information. The Provider Manual states “Independent pharmacies are required to maintain NCPDP Part I and II with accurate and current information at all times as Elixir utilizes this information during its review.” Furthermore, the provider manual states “email is the preferred method for Pharmacy communications by Elixir. Pharmacies will be notified of any audit communications via fax unless the Pharmacy FWA Department has been notified of email preference”. The email to communicate an update in audit communication preference is PharmacyAudits@elixirsolutions.com
PAAS Tips:
- Update your safe sender list and/or junk mail to ensure any audit notices sent via email are received
- Educate pharmacy staff to watch faxes and email carefully for any PBM communications – tossing an audit can be costly
- Consider using an electronic/paperless fax system that records/retains all incoming faxes
- Ensure your pharmacy’s NCPDP profile is kept up to date as this is a primary means for many PBMs to gather pharmacies’ contact information – this should be updated whenever a change occurs
- Designate an email address that is routinely monitored to avoid missing timely audit communications
Missing PBM Audit Notifications: How Are They Supposedly Sent?
At times, pharmacies fail to receive audit notifications, even though PBMs record them as “successfully” delivered. Thus, understanding how PBMs communicate with pharmacies can be beneficial. Here, we will examine the communication methods outlined in each major PBM provider manual:
Caremark
Caremark’s Provider Manual states “notices will be delivered in person by mail, via fax the Provider’s fax number or by email via the email address provided by Provider in Provider’s enrollment documentation or as otherwise indicated by Provider to Caremark and agreed to by Caremark or via Pharmacy Portal.” It goes on to say that it is the responsibility of the provider to notify Caremark when contact information needs to be updated. There can also be times when Caremark will communicate via phone to pharmacies, most commonly seen with desk audits.
OptumRx
OptumRx’s Provider Manual states “Provider understands Administrator relies on the information about its Provider, as well as each Pharmacy location provided by NCPDP and directly to Administrator, therefore, Provider: (1) Agrees to update in a timely manner all information in the NCPDP database whenever … and (2) Immediately notifies ORx and NCPDP of updated contact information at pharmacyprograms@optum.com,including changes in telephone numbers, fax numbers, email address.” In addition, it states OptumRx may communicate via telephone, mail, fax, and/or email when it comes to conducting their audits.
Express Scripts
Express Script’s Provider Manual states “All changes to Provider demographic information for independent Network Providers must be submitted by logging onto https://www.esiprovider.com and completing the online Change of Demographics form. Provider shall also submit updated demographic information directly to NCPDP and/or any other third party website as applicable”. It also states Express Scripts will communicate via fax, email, or USPS when initiating an audit.
Prime Therapeutics
Prime Therapeutics uses the information pharmacies input to their NCPDP profile as their sole means of communication. In the Provider Manual, it states to go directly to the NCPDP’s website https://online.ncpdp.org to submit changes. Prime Therapeutic’s system will incorporate all new NCPDP updates on a weekly basis.
Humana
Humana’s Provider Manual states “[Humana] will notify all pharmacies via traditional mail (UPS or certified mail). If you prefer to be notified via email, we can send letters via secure message. To notify HPSX of your notification preference, please send an email to pharmacyaudit@humana.com.”
Elixir
Elixir also utilizes NCPDP to elicit pharmacy contact information. The Provider Manual states “Independent pharmacies are required to maintain NCPDP Part I and II with accurate and current information at all times as Elixir utilizes this information during its review.” Furthermore, the provider manual states “email is the preferred method for Pharmacy communications by Elixir. Pharmacies will be notified of any audit communications via fax unless the Pharmacy FWA Department has been notified of email preference”. The email to communicate an update in audit communication preference is PharmacyAudits@elixirsolutions.com
PAAS Tips:
2024 Self-Audit Series #4: Transferred Prescriptions
Making sure your transferred prescriptions are complete can be one of the easiest audit recoupments to prevent.
Transferred prescriptions can easily be targeted for audit based on the origin code billed on the claim. High dollar claims with an Origin Code of 5 have an increased likelihood for audit. Consider utilizing this information to self-audit your transferred prescriptions on a regular basis.
PAAS Tips:
OptumRx Continues to Cause Headaches!
PBMs monitor, and flag, migraine medications due to excessive cost, quantities submitted, days’ supply (and/or frequency of refills) and vague instructions. OptumRx often flags …
PAAS Tips:
Pharmacy Owner’s Involvement in Fraud Scheme Leads to 4-Year Prison Sentence
The Department of Justice recently announced the sentencing for a New York pharmacy owner. A four-year prison term, three years extended supervision, and paying back restitution of more than $6 million dollars, is the outcome for this owner based on his involvement in a Medicare and Medicaid fraud scheme.
Investigators from the Federal Bureau of Investigation, the Office of Inspector General, and the U.S. Department of Health and Human Services discovered Medicare, Medicaid, and private insurance companies paid approximately $5.2 million dollars in fraudulent HIV claims to this pharmacy from 2021 to 2022.
The pharmacy owner was paying illegal kickbacks to low-income HIV patients if they would fill their expensive medications at his pharmacy. Part of this scheme was to repurchase (back from the patients), the unopened bottles of the expensive medications at a fraction of their actual value. These medications would then be “re-used” over and over, while never actually being dispensed to the patients.
The investigation also discovered the pharmacy owner was unlawfully selling pharmaceuticals to other pharmacies that had been obtained from illegal sources.
Ensure your pharmacy has a robust Fraud, Waste and Abuse Compliance Program in place for employees to understand the repercussions of violating laws and regulations such as the False Claims Act and the Anti-Kickback laws. Contact PAAS National®® (608) 873-1342 for more information on PAAS’ FWA/HIPAA Compliance Program that is easy to set-up, web based and customized for your pharmacy.
Audit Risk: Billing DAW 1 Unnecessarily
In a time where every aspect of prescriptions is scrutinized, PAAS National® wants to ensure you don’t forget simple filling and billing practices; in this case, using DAW 1 appropriately. PBMs can flag pharmacies who use a high volume of DAWs (other than zero), increasing your pharmacy’s audit risk. A simple way to decrease the amount of non-DAW 0 claims that are being adjudicated is to …
This includes situations where the prescription comes to your pharmacy indicating “Dispense as Written” per prescriber. The best practice in those scenarios would be to contact the prescriber and inform them a DAW 1 is not appropriate since there is no product on the market deemed to be substitutable. Subsequently, make a full clinical note on the hardcopy with the date, name and title of the person you spoke with, a recap of the conversation, and your initials.
If there are questions regarding proper DAW use, refer to the DAW Codes Explained tool, which can be found under the “Proactive Tips” section on the PAAS Portal.
PAAS Tips:
Diagnosis Restricted? Documentation Required!
PAAS National® is starting to see more audit recoupments on claims where a diagnosis code was required at adjudication but there was no documentation on the hardcopy to support the diagnosis code billed. PBMs may prompt pharmacies to enter a diagnosis code on claims when the medication billed is only covered for certain indications, helping to take the guesswork out of coverage limitations.
Common diagnosis restricted drugs include GLP-1 (e.g. Trulicity®, Ozempic® and Mounjaro®), Nuedexta®, stimulants/ADHD medications, and Naltrexone. It is important to ensure the diagnosis code is present on the prescription or verified with the prescriber and a clinical note added to the prescription if you are prompted to enter a diagnosis code during claim adjudication. Do not process prescription claims for an assumed diagnosis code. Without any documentation to support the diagnosis code entered, the claim is likely to be flagged for recoupment if audited. Repeat prescriptions with a prior diagnosis code can likely be deferred to professional judgment but should have the diagnosis code (with a clinical note) transferred onto the new hardcopy to avoid audit trouble.
PAAS Tips:
2024 DMEPOS Series #4: Surgical Dressings
Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements. Medicare Part B suppliers need to be able to produce all the required documentation if audited, and make sure all documentation meets Medicare Part B standards. This DMEPOS series is intended to help you understand these complexities and gather the needed documents.
In particular, you should be able to show the following if audited on surgical dressings:
PAAS Tips:
PAAS Audit Assistance members can search the Newsline archive for keyword “DMEPOS series” to read previous articles in this series. If you have any questions on accessing the Member Portal, or need help adding employees so they have access, please contact us at (608) 873-1342 or info@paasnational.com and our staff can assist you.
Do I Need to Consider Beyond Use Dating for Multi-dose Vial Medication?
The answer is YES! Multi-Dose Vials (MDV) for injection have Beyond Use Dates (BUD) that need to be followed. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The manufacturer’s expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer’s original expiration date. Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed.
The MDVs typically contain an antimicrobial preservative to help limit the growth of bacteria; however, over time, sterility can be impacted. All MDVs for injection will have a beyond use date – in some cases it is specifically identified in manufacturer labeling, in other cases it is not specified. If not specified, pharmacies will need to refer to The Joint Commission guidelines to assign BUD for multi-dose vials (explained below). Pharmacies should use the shorter date (beyond use OR days’ supply calculated per the instructions) when considering what days’ supply to submit (and corresponding refill intervals). Refer to the latest PAAS National® Insulin Medication chart for BUD information for various insulin vials. Remember that each insulin vial has its own BUD!
Example 1: Lantus® vial, 10 mL: Inject 20 units q HS = 1000 ÷ 20 = 50-day supply but should be discarded 28 days after opening (first needle puncture)
Example 2: Levemir®, 10 mL: Inject 20 units q HS = 1000 ÷ 20 = 50-day supply but should be discarded 42 days after opening (first needle puncture)
Here are a few common questions & answers that may assist your pharmacy in filling and billing MDVs accurately:
Q: Do I have to bill the correct days’ supply if it pushes the patient into a 2-month copay?
A: Most likely yes; if you are contracted for an extended days’ supply plan you must bill an accurate days’ supply. If the patient isn’t happy about their copay, pharmacy staff, or the patient, could try to call customer service in an attempt to obtain a copay override (since they are not getting a full 2 months). The pharmacy must submit the days’ supply as supported by the instructions for use and beyond use dating unless given specific approval in advance from the PBM help desk. Don’t forget to document any help desk calls using the 4-element clinical note format on the prescription hardcopy.
Q: When should multi-dose vials be discarded?
A: Medication vials should always be discarded whenever stability or sterility is compromised or cannot be confirmed. In addition, The Joint Commission recommends the following for multi-dose vials of sterile pharmaceuticals:
PAAS Tips:
Why You Should Care About PBM Provider Manuals (and Where to Find Them)
Whether your pharmacy contracts directly with a PBM or the agreements are negotiated through a Pharmacy Services Administrative Organization (PSAO), the terms and conditions within the agreements are just the beginning of a pharmacy’s obligations. Additional expectations for the pharmacy are laid out in the PBM’s Provider Manual. Understanding and following the stipulations contained therein can help decrease your risk of audit recoupments and keep the pharmacy in good standing. However, these manuals vary significantly by PBM, often exceed 150 pages, and can get updated multiple times throughout the year – making it impossible for pharmacies to keep up with all the requirements. Making matters worse, PBMs do not accept a plea of ignorance and violating the provider manual can lead to claim recoupment, accusations of fraud, waste, or abuse, and even contract termination!
Through our Newsline and audit assistance, PAAS National® helps pharmacies stay abreast of these changing requirements as they relate to audits. To access the Provider Manuals directly, follow the links below:
PAAS Tips:
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. OptumRx asked pharmacies to provide copies of insulin prescriptions as well as the associated fill histories, signature logs and explanation of payment for these insulin prescriptions dispensed between July 2019 and June 2023.
Most pharmacies report dispensing no insulin to the patients in question and explained that the alcohol swabs were being used in conjunction with diabetes testing supplies (test strips, lancets) that were also billed to OptumRx. Since OptumRx covered the cost for diabetes testing supplies, it would suggest that patients were enrolled in a Medicare Advantage (MAPD) plan and OptumRx incorrectly categorized the alcohol swab claims as “Part D” when they should have categorized as “Part B”. The OptumRx audits seem to stem directly from a nationwide CMS audit of Plan Sponsors initiated in December 2023. During this audit, CMS scrutinized Part D claims for medical supplies, such as alcohol swabs, in cases where patients lacked any claim history for insulin use.
The coverage of insulin and its related supplies may vary depending on the Medicare benefit type and the intended use of the item. Specifically, insulin vials and alcohol swabs could be eligible for coverage under either Medicare Part B or Part D.
Keep in mind that Medicare patients could have prescription and medical benefits that are separate or combined.
Here is a chart to help you identify the correct payer depending on the type of Medicare benefit and the item in question.
(Part B/DMEPOS)
(MAPD)
A few nuances to keep in mind:
PAAS Tips: