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.