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Onsite Audits |
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The pharmacy is notified of a scheduled Pharm/DUR audit. Independents usually request hard copy notification
while most chains are scheduled electronically with the corporate office. The reviewer calls and verifies
the audit date with the pharmacy. The reviewer is equipped with a Laptop computer and a portable scanner.
The reviewer presents a Pharmacy Auditors Credentializing Report along with a Sig Log Request Form to the
pharmacist. The reviewer also has a Pre-Audit Report containing the unique prescription numbers, dates of
fill and drug name. The On-site© Audit application provides the auditor with a view of all the claim
information submitted and processed for a specific prescription in the review claims dataset.
The auditor can then compare the information from the original hard copy of the prescription
with the information submitted for payment. Inconsistencies and other informational discrepancies
are noted on the computer screen. The program will request a scan of the prescription for any
identified discrepancy. Notes, questions and free form observations are captured through the use of
drop down menus. Our in-house pharmacists use these remarks to complete the review. Each individual
claim is reviewed and checked for completion before the auditor can sign off and move to the next
prescription. Reviewers are asked to use their Retail pharmacy background to provide observations on
pharmacy appearance, type of inventory and standards of pharmacy practice. The reviewer leaves behind
a Field Audit Report containing general discrepancy types and other pharmacy specific information.
The pharmacist must sign this report. This completes the First Phase of the In Store Audit.
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The reviewer then uploads the completed preliminary audit onto a
secure site. The audit is downloaded at the Pharm/DUR offices the
next morning. The preliminary audit is reviewed and the in house
pharmacist applies appropriate plan rules and regulations to the
audit. After this second review a preliminary report is sent out
to the pharmacy electronically or via US Mail. The pharmacy has
approximately 30 days to submit any post audit documentation that
might mitigate the noted discrepancies. A final audit report is
sent to the pharmacy when the post audit documentation period
has elapsed. All audits are available for authorized client review
via a secure web site. All discrepancies are line item detail.
Pharm/DUR does not use extrapolation techniques.
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In addition, to set up the proper dataset file, Pharm/DUR, Inc. would require a sample of
recent data with all paid claims, and claims file layout. Upon completion of the data file
test, complete claims data to begin the review. In order to conduct audits appropriately,
Pharm/DUR, Inc. would require plan benefit documentation, contract agreements with the PBM,
implementation worksheets, and any other documentation necessary to define plan parameters.
In the case of multiple benefit designs, we would require a benefit grid, preferably in electronic
format in order. A primary contact with a client liaison, to answer questions related to the plan
administration and benefit design as they come up in the course of the review process.
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Through a number of proprietary and customized rule sets, the AudiTrack©
application will identify and report claims discrepancies. Criteria can include but not be limited to:
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- Gross Claims Volume
- Brand/Generic Utilization
- Controlled Substance Utilization
- DAW Submissions
- One time Submissions (maintenance drugs, creams, antibiotics, Etc.)
- U&C Submissions
- Incorrect Prescriber Submissions
- Incorrect Days Supply Submissions
- Multiple Package Supply Submissions
- Percentage of prescriptions filled for a specific physician
- Maximum Dose Limits
- Submission of Stale or Outdated NDC numbers
- Compounds submitted with an indicator
- Compounds identified and Not Submitted with an indicator
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Any discrepancy, fraudulent or abusive billing patterns will be flagged and reported to
client for further determination before proceeding with recovery. Our solutions are specific
to your requirements and evolve with your changing needs.
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The AudiTrack© program processes pharmacy data for stores
that have not reached a specific claims volume. Proprietary and
pre determined edits identify the pharmacies and specific claims
for desk review. The initial investigations are identified through
the results obtained when we submit a client’s claim data to the
rigorous system review using the AudiTrack© application.
The Pharmacy Desk Audit Program is utilized in instances where
the system identifies a data trend potentially fraudulent or
abusive in nature or where the claim volume of a specific
pharmacy is not sufficient to be included for an on-site audit.
Overall, we provide our clients with approximately 10% to 20% of
the total audits completed as desk audits. The Desk Audit Program
does not preclude the continual and systematic review of claims
for inclusion into an On Site Audit.
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