Pharmacy Compliance Audits: What Pharmacists Can Expect

Independent community pharmacists should be prepared for pharmacy compliance audits, as pharmacies have been seeing more of them.

Here’s what the audit process looks like:

Before the Audit

An audit and compliance vendor will send you a notice stating plans to visit your store and perform an audit. These vendors contract with third-party prescription insurance companies to perform audits on their behalf.

Your assigned representative will call you and confirm your appointment about 2 weeks prior to the visit. You’ll receive a fax with a copy of all of the prescriptions that will be examined. Unfortunately, you won’t be provided the entire number; just enough information to pull the prescription file.

You’ll want to bring in some extra help the day of the audit, as most auditors require a pharmacy assistant throughout the entire audit process.

During the Audit

The questions asked by the auditor, although straightforward, may become a little complicated if the information isn’t readily available. Therefore, make sure the chosen assistant thoroughly understands your prescription billing and records process, as it will help expedite the answers to those seemingly monotonous questions.

Be sure to have your signature logs (electronic or manual), policies and procedures, and compound formula worksheets readily retrievable. Auditors will most likely ask to see your written policies on how you handle any compounding, no matter how little you do. They may also require you to show them your written policy on delivering medications to patient’s homes.

These audits have the potential to become a really big deal. Most audits will review claims submitted a full 24 months back and may look at 100 or more prescriptions in one afternoon. Any discrepancies found may be subject to an adjustment, unless you’re able to come up with appropriate documentation supporting the claim. Something as simple as an undocumented refill in the computer may amount to thousands of dollars in adjustments.

After the Audit

Shortly after the audit, you’ll receive full documentation of the findings and adjustments. You may see adjustments of several thousand dollars, which is money you’ve already been paid that the insurance company now plans to withhold from future payments until the amount is paid in full.

You’ll notice the auditors put their effort toward medications with the highest possibility for financial withholding. Don’t be surprised if your audit looks at all of your expensive narcotic prescriptions, insulin pens and vials, brand-name inhalers, and any other medication that was reimbursed for more than $500.

However, don’t panic, as all of the findings can be appealed. You’ll usually have 30 days to submit supporting documentation to correct your adjusted claims.

Review each adjustment carefully. If the prescription is missing refill authorization, contact the prescribing physician and explain the situation. Ask the physician to document on letterhead the missing refill authorization. You’ll be surprised how willing physician’s offices are to help you out with this.

Days’ supply adjustments can usually be appealed for partial payment. Even partial payments on expensive medications are well worth the effort.

Conclusion

Pharmacy audit preparation is done every day with proper workflow. Maintain clear communication with your team so everyone working to fill the prescription understands the importance of complete and appropriate documentation.

Focus on expensive medications where days’ supply isn’t always obvious. Insulin, drops, topicals, inhaled therapy, and liquids quite often require calculations.

Independent community pharmacists work very hard for their insurance reimbursement. The last thing we need is to miss some part of the documentation process and have the entire reimbursement adjusted back to the insurance company.