On July 26, 2024, the California Department of Healthcare Services (“DHCS”) – which administers California’s Medicaid program – sent Notices of Medi-Cal Desk-Audit (“Audit”) to numerous California pharmacies. It appears that pharmacies that bill expensive specialty medications to Medi-Cal are subjects of these audits.
The Audit requests an overwhelming amount of information: from business ownership/
I recently assisted a pharmacy in a PBM audit where we had to address unauthorized refills. The PBM was recouping a substantial amount of money because a medical assistant was signing refill authorizations. While medical assistants often sign for refills, they need do so with their supervising prescriber’s credentials.
California law defines medical assistants as
Enforcement actions against compounding pharmacy have been headliners for some time. Today’s post focuses on a last year’s action against a L.A. pharmacy for paying illegal kickbacks to marketers and waiving patients’ copays. The pharmacy – Fusion Rx Compounding Pharmacy – was improperly paying two marketers for steering expensive prescriptions to the pharmacy.
According to
Today I would like to highlight some practical aspects in appealing PBM audits. Earlier this year, a PBM denied several pharmacy audit appeals because pharmacies were not compliant with the provider manual when presenting their appeal paperwork. Namely, the additional documentation presented by the pharmacy lacked pharmacy NABP number, prescription number, and date of fill.
The United States Attorney’s Office for Southern District of Florida has recently announced a settlement with three Florida pharmacies to resolve allegations that they fraudulently used collaborative practice agreements (“CPAs”) to bill federal health care programs for unlawfully prescribed medications.
In its press release, the governments explains that “A collaborative pharmacy practice agreement is
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
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
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
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:
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