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Sunday, March 1, 2015
APha: Fighting for fair PBM auditing practices, state by state March 1, 2015
Good. Auditing is a good practice for any business. However, once the audit nit-picks clerical errors for the sole purpose of reclaiming funds, the audit has lost its originally intended purpose.
PBM audits can be catastrophic to certain pharmacies due to one insignificant mistype on a prescription.
My pharmacy had the unpleasant dealings with CVS Caremark a few years back. They want roughly $40,000 back due to the prescriptions signed by a PA rather than the doctor. $40,000 for a nitpick. It was over 50 prescriptions that needed each individualized signature of the doctor, re-signed and documented, with many wasted man hours to fight this audit.
I'm sure you'd be fine if your insurance denied your claims for a car accident if your date of birth was wrong?
Like I stated, once the audit turns from clarification of a claim to the sole purpose of reclaiming funds the meaning of audit has been twisted and skewed.
Mispelling a name on a prescription of John vs Jon and having the insurance recoup all funds due to the clerical error is ridiculous, especially if extremely expensive cancer drugs are involved.
Wrong birthdate on insurance claim would be denied and require it to be fixed before claim would be approved. This is true of most things in life. How does the auditor know it is clerical vs. on purpose? Where do you draw the line? You might have made an honest mistake, but the next person in line with a very similar issue might have done it for fraudulent reasons.
4 comments:
Good. Auditing is a good practice for any business. However, once the audit nit-picks clerical errors for the sole purpose of reclaiming funds, the audit has lost its originally intended purpose.
PBM audits can be catastrophic to certain pharmacies due to one insignificant mistype on a prescription.
My pharmacy had the unpleasant dealings with CVS Caremark a few years back. They want roughly $40,000 back due to the prescriptions signed by a PA rather than the doctor. $40,000 for a nitpick. It was over 50 prescriptions that needed each individualized signature of the doctor, re-signed and documented, with many wasted man hours to fight this audit.
What may seem like nit-picks to you are rules to others that must be followed.
I'm sure you'd be fine if your insurance denied your claims for a car accident if your date of birth was wrong?
Like I stated, once the audit turns from clarification of a claim to the sole purpose of reclaiming funds the meaning of audit has been twisted and skewed.
Mispelling a name on a prescription of John vs Jon and having the insurance recoup all funds due to the clerical error is ridiculous, especially if extremely expensive cancer drugs are involved.
Could you ethically defend such audit practices?
Wrong birthdate on insurance claim would be denied and require it to be fixed before claim would be approved. This is true of most things in life. How does the auditor know it is clerical vs. on purpose? Where do you draw the line? You might have made an honest mistake, but the next person in line with a very similar issue might have done it for fraudulent reasons.
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