2024 Self-Audit Series #3: Invoice Audits
The number of invoice audits continues to rise from Medicaid, and PBMs, across the board. This investigational audit is a way to potentially identify false or phantom claims. Auditors will reconcile the claims billed by a pharmacy during a certain timeframe, with the purchases made. This process ensures the pharmacy had inventory on hand to dispense for the claims they billed. Many PBMs, including OptumRx®, Elixir®, and Express Scripts® request pharmacies provide a full dispensing history for further reconciliation.
Some inventory audits are frequently combined with a desk audit. PBMs like Caremark request a high number of prescriptions, signature logs, and proof of copay collection. The amount of data a pharmacy is required to provide can be very overwhelming and time consuming. Performing internal, “mock audits” may help you be better prepared when receiving an invoice audit request.
Pharmacies must be diligent in following PBM requirements for purchasing. Audit recoupments can easily reach hundreds of thousands of dollars when invalid purchases are not accepted.
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- Wholesaler:
- Keep a running list of wholesalers you are purchasing prescription and over-the-counter (OTC) items billed as prescriptions
- Vet each wholesaler to ensure they meet PBM requirements and can provide pedigrees in accordance with FDA Track and Trace Law
- Each wholesaler must meet state licensing requirements
- PBM Specific:
- OptumRx requires National Association of Boards of Pharmacy (NABP) Drug Distributer Accreditation, formerly known as VAWD
- Caremark and Express Scripts require all diabetic supplies be purchased from an “authorized distributor”
- See July 2021 Newsline, LifeScan Hires Law Firm to Pursue Pharmacies Purchasing from Unauthorized Distributors
- Caremark requires notification and approval of any bulk purchasing the pharmacy makes
- See February 2024 Newsline, Caremark Bulk Purchase Notification
- Caremark auditors now require original invoices for any pharmacy-to-pharmacy transfer, including MatchRx and Rxeed™
- See April 2024 Newsline, Caremark Invoice Audits-Purchases from Other Pharmacies
- General:
- Keep copies of all invoices and proof of purchases for 10 years as required by Medicare Part D retention requirements
- Adhere to Return to Stock policy and be sure claims are reversed appropriately
- Be sure the NDC you billed is the same as the NDC you are dispensing
- For tips on performing a self-audit, see our January 2020 Newsline, Self-Audit Series #12: Invoice Audits
I attended Madison College in nearby Madison, WI (PAAS headquarters are in the Madison suburb of Stoughton). Prior to coming to work at PAAS, I worked as a Certified Pharmacy Technician in a retail setting for 25+ years. Pharmacy has been my life’s work.
Helping our members have a successful audit experience is very rewarding. Celebrating with them, when PAAS often helps generate positive post-audit results, is the best part of my work.
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