Working collaboratively can be key to either avoiding a PBM audit altogether or making the process as painless as possible.
They nearly always cost pharmacies money and require a lot of work to complete, but pharmacy benefit manager (PBM) audits are an unfortunate fact of life. At the National Community Pharmacists Association 2022 Annual Convention & Expo, presenters shared their insights into how pharmacists can tackle these audits in the most effective way possible.
Curious why audits happen? It’s as simple as rising health care costs and improvements in data analytics that find outliers more easily, according to Dana Westberg, CPhT, analyist at Pharmacy Audit Assistance Service (PAAS), to say nothing of the revenue generated by them, as one of the most common penalties is financial recovery. Bad actors also make PBM audits necessary: Westberg cited 2 cases, one involving a pharmacy in Texas that had $10 million in dispensing expenses and another involving pharmacy owner/accountant who was indicted for a $1.5 million scam.
Trent Thiede, PharmD, MBA, PAAS president, cited his own examples of bad actors, including one case of a pharmacist who billed products that were never dispensed over a period of time that netted $7.2 million, another about a group of ghost pharmacies in Miami that billed for products for pharmacies that did not exist, purchased no prescription drugs, had no real customers, and performed no actual pharmacy business.
Those bad actors have led to a 50% increase in audits over 5 years. Desktop audits remain the most common form. Onsite audits decreased with the onset of COVID-19, but were replaced by virtual audits, which “tend to be very large, very time consuming and you also have a phone interview with the auditor,” according to Westberg.
Westberg shared 4 strategy elements to prevent audits, which include:
According to Westberg, common audit discrepancies included prescriptions that were missing elements, transferred prescriptions lacking transfer elements, overfilling prescriptions, filling refills too soon, and dispensing outside of a return to stock. She noted that although many pharmacies operate on a 14-day return to stock policy across the board that some PBMs have moved to a 10-day standard.
Implementing workflow strategies as a key part of the dispensing process can be a good way to make an audit easier and can include:
When the subject of a PBM audit, many owners choose to take on the audit themselves and not involve staff. For Westberg this may not be the best idea, it can leave staff in the dark about what drugs can trip an audit and the consequences of an audit. “A lot of your staff may not be aware of that. And by sharing this information [it] really may change how they're doing their job.”
Drug Topics’ coverage of the 2022 NCPA Annual Convention and Expo is sponsored Prescryptive Health.