Planning your pharmacy audit response: A Q&A with Joy Gray

 

Joy Gray, PharmD, Pharmacy Manager for Tennessee Cancer Specialists, describes herself as an “audit queen.” Her practice has successfully navigated several audits from pharmacy benefit managers (PBMs), a process that may seem daunting or overwhelming for many practices.

VitalSource™ GPO spoke with Joy about how practices can empower themselves with strategies for audit preparation, responding to audit requests and how your GPO and pharmacy services administrative organization (PSAO) can help.

In my experience, adjudicating claims outside of business hours can trigger a claim. In our practice, we went through a transition period where there was staff turnover. Due to limited resources, I was processing claims late in the evening, which triggered an audit. The feedback we received from the auditor was that the claim was processed outside of the hours of operation listed on our profile and the hours on record with the PBM.

We have also been questioned about the days supply of inventory we have on hand. If you’re not currently doing so, make sure your inventory on hand matches the on-hand supply you have documented in your policies and procedures.

It’s also important to ensure that prescriptions are either picked up or returned to stock. This is another area where we have received comments from auditors, and another example of why it’s important to ensure that your documented processes and procedures are being followed.

It’s important to keep in mind that most pharmacy benefit managers (PBMs) have the ability and authority to conduct audits at any time on behalf of the plan sponsor or manufacturer to ensure that practices are following standard protocols in their medically integrated dispensaries. As a result of necessary social distancing and safety procedures, you can expect to see more requests for virtual audits from certain manufacturers. We have seen more requests for virtual audits already in areas with higher rates of COVID-19 infection.

Your first line of defense in navigating an audit should be your staff. Therefore, training your staff and ensuring that your practice’s policies and procedures are documented and up to date is critical. Ensuring open lines of communication among your staff and with your physicians is also valuable and something that will be beneficial in the event of an audit. Our practice developed a communication log that is used to document updates and new pieces of information that we learn from PBMs. Whenever we learn something new that could help us be more prepared for an audit, we put it in the log.

Another strategy we have implemented is working with our experienced staff members to conduct self-audits on a regular basis. Performing regular self-checks and walking through our processes and procedures can help identify areas for improvement and affords us an opportunity to correct potential problems before an auditor is onsite. If your practice does not already have someone designated as an audit expert, you should consider assigning an experienced team member who is well-versed in your policies and procedures to lead your audit preparation strategy.

Again, it’s important to have a solid audit response strategy in place prior to being audited. A key component of this strategy is being prepared to potentially challenge unfavorable results and thinking about the information and resources you will need to respond.

Receiving unfavorable results from an audit may seem overwhelming at first, but it’s important to identify what your options are. Final decisions are not necessarily final – you may have the ability to appeal the results. When our practice has received a negative result in the past, we have often appealed several times until the issues were corrected.

The resources offered by your GPO and/or pharmacy services administrative organization (PSAO) are invaluable. The VitalSource™ GPO team and the LeaderNet PSAO have been invaluable to us. They were able to provide support and dig into the documentation to help us craft our responses to audits. Even when we have been surprised by unplanned audits or come across unexpected challenges, the Site of Care Dispensing team has been there to help ease our concerns, provide us with the information and guidance we need and give us peace of mind. They have also helped us better understand PBM requirements and processes. They have truly taken the burden off our shoulders and stood alongside us during audits so that we can focus on taking care of our patients.

For more information on audit preparation and updates during COVID-19:

• Access the Pharmacy Audit Assistance Service COVID-19 PBM concessions chart 
• Visit the VitalSource(TM) GPO members-only website
• Contact the Site of Care Dispensing team

*The information provided in this article is intended for general informational purposes only and does not, and is not intended to, constitute legal advice. You should contact your attorney for advice on your practice’s contracts with payors, audits by pharmacy benefit managers or any other legal matter. You should not act or refrain from acting on the basis of the information in this article without first seeking legal advice from counsel.