PIC provides onsite pharmacy audits, which allow PBMs and managed care health plans that directly contract with network pharmacies to quickly identify and disrupt healthcare fraud occurring at retail, mail order, long term care and hospital pharmacies within the network. Using the COPs software we are able to successfully find inappropriate relationships between prescribers, pharmacists and patients, reducing costs and liability for your company and your clients.
How do we determine which pharmacies to audit?
PIC begins each audit by identifying and ranking the pharmacies within the network to determine best targets for audit using the COPs software. Pharmacies that have demonstrated inappropriate billing or dispensing behavior will quickly and efficiently be revealed through the COPs software. COPs then performs a sophisticated data mining analysis that encompasses each and all claims, which can be customized to specifically target issues identified by our clients. Based on each pharmacy’s deviation from legitimate billing and dispensing practices, each pharmacy receives a score based on criteria such as:
- Brand–generic interchange
- Day’s supply
- Cost
- Controlled substance
- Number of claims
- High dosage
- Duplicate claims
- Reversed claims
- DAW
- Prescriptions/patient/month
- Cost/patient/month
- Quantity
- High dollar claims
- High number of refills
- After hours processing
Additionally, PIC applies the knowledge and expertise gained through years of experience to further identify pharmacies for audit based on recognized trends, geography, ownership, and pharmacy type such as Specialty or Compounding. Social media investigations are quickly performed, scanning for links with Facebook, Vine and Link-in, prior arrests and license infractions to find connections that further establish and verify fraudulent behavior.
What does a PIC audit entail?
PIC uses a combination of requesting information to be sent ahead of the actual audit and some element of “surprise” by also requesting information on-site, which keeps our audits cost effective. Examples of information that may be requested from pharmacies before or after the actual audit:
- HIPAA compliance materials
- Return to stock procedure
- Copies of all pharmacists, technician, DEA, and State licenses which are then checked prior to the onsite audit through the state websites.
During the actual on-site review, our pharmacist/pharmacy technician teams review the following:
- Copies of up to 50 prescriptions and related refills
- Accounts receivable information to ensure copays are collected.
- Copies of related signature logs or electronically recorded signatures
- Medication Returned to Stock procedures are observed
- If Controlled inventories are up to date and properly maintained
- If the refrigerator and required logs are maintained properly
- If the pharmacy is clean, neat and organized
- If the pharmacist offers patient counseling and conversations are observed for compliance
- If the pharmacy complied with HIPAA and OBRA regulations
- If the pharmacy was in compliance with pharmacist/pharmacy technicians ratios of staff requirements
- If inventory is out of date or insufficient based on volume.
A thorough investigative report details issues with the pharmacy’s operation, provides corrective action plans for process improvement and other strategies that mitigate risk for health plans and PBMs. Detailed spreadsheets provide claims identifiers to quickly and efficiently reverse fraudulent claims.