Community Forum : New Practitioner Network
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 Subject : Fair Pharmacy Audit Reform.. 08/25/2017 01:53:02 AM 
J Cody Sandusky
Posts: 3
Good evening, everyone!

Being brand new to the world of independent pharmacy, I guess I was clueless on just exactly how much PBMs dictate (or try to dictate) our practices as pharmacists. I knew they did, but perhaps not quite to the extent. Or maybe, perhaps, I was naive. In the last four weeks, our pharmacy has been audited by two PBMs (40+ Rx each, one an in-house audit). Many of the claims in question pertained to Medicare B vs. D determination, but perhaps not so ironically never focused on any of the scores of "cheap" Medicare determination claims that could be questioned, but instead centered on high-dollar items. In all my years in working for a chain, I never recall having that magnitude of prescriptions audited, not to mention with such scrutiny. Maybe a handful a year. But never eighty-something scripts in one week.

"Que sera, sera!" Right? Nothing unheard of: Big PBM vs. Little Pharmacy. Goliath vs. lowly goat herder. Maybe not. It piqued my interest, and I did just a little research. A lot of the information I found is a little dated, so if you have more current information, please share with me, but as far as I can tell, Illinois is one of the most PBM-friendly states so to speak in terms of lack of regulations. Thirty states, including most states surrounding Illinois, have adopted some form of fair pharmacy audit reform, as well as various other PBM reform bills. There are currently two bills in the Illinois House and Senate each addressing pharmacy audits and PBM reform. I have provided links below to an article from the Independent Pharmacy Cooperative highlighting those, as well as links from articles from NCPA.

Has anyone else noticed any of these trends, especially those of you in the independent pharmacy world? Or perhaps those that have worked in both the chain and independent side of things?

If so, let's chat at Annual Conference in a couple weeks!
 Subject : Re:Fair Pharmacy Audit Reform.. 08/25/2017 02:27:13 AM 
Brittany Hoffmann-Eubanks
Posts: 7
My pharmacy has had two audits in the last 3 months (two separate insurance plans) and both consisted of over 100 prescriptions being audited each time. The first audit went very well, however, the second was a disaster with 25 discrepancies. To your point, there are no standards with respect to auditing practices, so, they can make up whatever they want. For example, almost half of my discrepancies were related to faxed prescriptions in which the auditor couldn't read the full fax transmission at the top (even though it was there partially and clearly faxed) therefore, making that an invalid Rx in their point of view. So, now I will have to contact every doctor for each Rx to try and get a letter stating they did in-fact fax this Rx to reclaim my dollars. A colossal waste of time and energy that is taken away from my patients. I work for a large retail chain...but we are hit just as hard. They always focus on high-dollar items, package sizes, compounds,....etc.
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