PAAS National® analysts have noticed an increase in PBM audits focusing on copay collection. These audits requested a copy of the pharmacies’ policies and procedures addressing copay collection and financial hardship.
Pharmacies often see PBM audit letters requesting documentation to validate paid claims, but not very many see letters sent to their patients.
A September 30, 2023, Department of Justice press release outlined a recent settlement between the U.S. government and a specialty pharmacy based in Delaware.
There are two RSV vaccines FDA-approved for people ages 60 years and older – AbrysvoTM and Arexvy®.
Some pharmacies are wondering if they are allowed to continue prescribing OTC COVID-19 tests.
The top audit discrepancy year after year is invalid days’ supply or refill too soon – which are essentially the same issue.
PAAS National® continues to see PBM audits increase as we get further out from the formal end of the COVID-19 Public Health Emergency. One disturbing trend is the number of invoice audits, particularly from Caremark.
PAAS National® analysts receive many questions on Ozempic® relating to concerns about off label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing.
PAAS National® analysts have recently seen an increase in desk audits for worker’s compensation claims, mostly performed by Script Care.
Most pharmacies have grown accustomed to desk audits and providing copies of prescriptions, signature logs, and even copay collection records to PBMs upon request. Additionally, many pharmacies can recount their most recent experience with an onsite auditor visiting their pharmacy and the numerous questions related to operations, policies & procedures, and credentialing. However, not as many pharmacies have experienced an invoice audit – the stakes are higher and honest mistakes can lead to very expensive lessons in the process.
