PBMs often flag telehealth claims and scrutinize the legitimacy of such scripts. When we see chargebacks based on “Invalid patient/prescriber relationship,” we know that it’s time for some legwork. We typically research (1) where the prescriber and patient were located; (2) whether prescriber was authorized to prescribe the medication in question; and (3) whether the
Audit defense and prevention – New product
I am always eager to learn new ways to help pharmacies stay on top of their compliance and prevent chargebacks and contractual terminations. That’s why I am excited to introduce you to PharmPilot.
It has four primary functions:
– Audit Pilot (my favorite): “proactive analysis of your pharmacy’s data to detect shortages and other
Risks of dispensing ivermectin
This month, the American Medical Association, American Pharmacist Association, and American Society of Health-System Pharmacists issued a joint release urging prescribers and pharmacists to stop ordering, prescribing, and dispensing ivermectin to prevent or treat Covid-19 outside of clinical trials. The reason for issuing this plea is a 24-fold increase in prescribing and dispensing of ivermectin
Another prosecution in connection with compounded medications
Compounded medications have been under government radar for quite some time. So a recent inditement and prosecution of two pharmacists and a marketer implicated in allegedly fraudulent scheme involving compounded medications comes as no surprise. The individuals allegedly defrauded TRICARE and private insurances by:
- price-testing and adjusting prescription formulas to ensure the highest reimbursement;
- using
Aberrant Quantities: watch your reversals
Pharmacy terminations based on aberrant quantities and products are becoming more and more prevalent. It is difficult to appeal such terminations due to broad definitions of aberrant products/quantities and PBMs’ excessive discretion on what constitutes such products and volumes.
For example, PBM manuals usually state that Provider “must not dispense aberrant quantities of” certain products
Making admissions in government investigations
If you operate a healthcare business, responding to government investigations and informal requests for information is an everyday reality. Your response to such investigations and requests can often decide the fate of your business (this is not an exaggeration, as the below examples show).
One common thread in many of my cases is the admissions
Correctly applying manufacturer coupons
I am starting a series of posts consisting of mini-topics that I covered during my December webinar. I had many questions regarding the information presented and will try to address some of the issues in this series.
Today I will be talking about manufacturer coupons, which is a common cause of significant PBM recoupments.
Let’s
The California Board reminds that only pharmacists can initiate immunization
In the most recent Script newsletter, the California State Board of Pharmacy explained that it received multiple complaints and observed practices where non-pharmacist staff were initiating the immunization process. It reminded that the authority to independently initiate and administer a vaccination extends only to pharmacists. The Board strongly encouraged pharmacies, designated pharmacists-in-charge, and pharmacists to
When applying manufacturer’s coupons could get a pharmacy in trouble
It is not uncommon for pharmacies to apply manufacturer’s coupons to assist patients with high deductibles. But when applied incorrectly, the pharmacy may face recoupments, audits/investigations, and large settlements as recent cases illustrate.
The U.S. Attorney’s Office has recently reached a $3.5 million settlement with specialty pharmacy Advanced Care Scripts, Inc. (ACS), to resolve allegations
Importance of accurately reporting Usual and Customary Drug Prices
Recently, we have seen many cases filed by whistleblowers against pharmacies for not properly reporting their Usual-and-Customary Drug Prices (U&C). The cases are usually filed under the False Claims Act (FCA) for manipulating U&C to receive greater reimbursements from government payors.
First of all, what is U&C? There is no uniform definition. Instead, third-party payor