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. These compliance reviews may include:
- Concurrent Claim Reviews (PAAS Audit Assistance members can see PBM Prescription Validation Requests Rose Nearly 20% in 2022 the February 2023 Newsline)
- Medicare/Medicaid Claims Review
- Telephone or Fax Inquires
- Aberrant Practices and Trends (typically via a Breach Notification Letter)
- Rx Claim Review
PAAS National® has recently reviewed a second round of these Rx Claim Review notices from members. While new for Caremark, PAAS has identified multiple versions of the letter primarily focusing on two areas of concern:
Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!
- Dispensed quantities of medications that are significantly higher than the average fill size
- Primarily seen with Diclofenac Gel 1%, Lidocaine 3% cream, Ketoconazole 2% cream and diabetic testing supplies (i.e., lancets, needles, strips, and syringes)
- Atypical dispensing activity (e.g., disparate prescriber to pharmacy ratio)
- Primarily seen with Duexis® and Pennsaid®
The brief, and poorly worded, letter states the pharmacy should evaluate the claims in question and consider whether the dispensing of these medications is appropriate. It concludes with “your cooperation is appreciated and will greatly assist us in our review”. Due to the ambiguous direction, pharmacies are unsure if they need to respond or provide any additional information or documentation to Caremark.
PAAS Tips:
- The notices PAAS has reviewed do not require a formal response
- Caremark wants the pharmacy to evaluate the claims
- For claims listed as having a high quantity utilization, pharmacy can verify the quantity and days’ supply dispensed for appropriateness
- For claims listed as having atypical dispensing habits, pharmacy should validate the claims are billed under the correct prescriber, that there is a valid physician-patient relationship, and that the prescriptions are not being solicited
- Every pharmacy’s situation is different and PAAS can help provide perspective and next steps
- See Caremark Expands “Aberrant” Language & Restricts Bulk Purchases from February 2022 Newsline for additional information on Aberrant Practices and Trends
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
- FDA Proposed Guidance for Biosimilar Updates - October 23, 2024
- Avoid OptumRx® Double Chargeback Pitfalls – Review Your Days’ Supply - October 1, 2024
- Unveiling a Health Care Fraud and Illegal Black-Market Conspiracy - September 17, 2024
