How to Safeguard Your Pharmacy Against PBM Audits Key Strategies to Ensure 100% PBM Billing Compliance
In recent years, it has become obvious that PBMs love their audits. With over 90% of your revenue going through a PBM, you must ensure 100% PBM billing compliance. The problem here is that PBMs have no issue switching up their rules or how they implement these rules. While it can start to feel like you’re stuck in a losing game, you can prevent disaster by staying ahead and being prepared.
there are also countless unapproved products that you’d rather not have in your pharmacy. Some unapproved other products that are PBM compliant are legacy products. Any other unapproved other products should be double-checked for their compliance before they hit your shelves. Coupon Audit Use your coupons carefully! Different
You have no other option, as the consequences of failing an audit can be catastrophic, resulting in a massive financial loss or even an end to your contract plan. It sucks, we know. Yet, if you stay ready, you never have to get ready. Specific PBM audit types you need to be aware of include the following: 100% Legal Prescriptions We may be stating the obvious, but it must be said: All your prescriptions need to be 100% legal. Are you following all legal protocols when filling prescriptions? Countless prescription types have their own filling requirements,
PBMs have different rules when it comes to using coupons, and
often, there are restrictions on what classification you can use coupons for. For example, Caremark allows valid online coupons, but only for FDA-approved
drugs , not supplements, 510(k) devices, or unapproved other products. A PBM will want to see your coupon use and copay collection to ensure you follow all coupon regulations. Invoices The most common PBM audit type is an invoice audit. To ensure you’re using only valid wholesalers, your PBM will want to check all your
and skipping any steps will come back to bite you when an audit occurs. Above all else, ensure you meet all of the legal requirements in your state when dispensing prescriptions. Test Claims Test claims aren’t inherently evil. As a pharmacy owner, you sometimes need to determine a prescription’s coverage for a specific patient. However, PBMs have become increasingly aggressive against test claims. Never go fishing for reimbursement data. You can get audited for reversed claims. The best way to avoid the hassle of a test claim audit is by avoiding them altogether. Instead, run a benefit check. You’ll get the same coverage information as a test claim without reimbursement and be PBM compliant. Unapproved Other Products Not all products are the same, and we all know that. Your stock has multiple FDA classifications: drug, supplement, 510(k) device, and unapproved other . Plenty of products are unapproved by the FDA but are perfectly legal to dispense. But
invoices for a specific period. That’s why you should keep a running list of all the sellers you buy from. Then, when the time comes to send your audit to your wholesalers, you won’t miss any and cause a headache later on. Always Be Ready for an Audit The last thing you want is to be hit with an audit out of nowhere, be completely lost on what to do next, and likely not be in 100% compliance. Instead, you should always use best practices to remain compliant and operate as best you can. You won’t have any reason to shy away from certain products, coupons, or prescriptions if you know exactly what needs to be done. This is the only way your pharmacy can genuinely thrive! Of course, if a PBM audit hits you and you need legal advice, we recommend Hunter Jamerson at the Macauley Jamerson Satterlund & Sessa law firm. Hunter is an experienced health care attorney specializing in PBM and contract cases. You can learn more about Hunter and contact his team at MacJamLaw.com .
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