Top Audit Discrepancies

PRESCRIPTION

Missing/Invalid Rx 

Altered Rx

Transfer Prescriptions

E-Prescriptions

Compound Prescriptions

Controlled Substances 

Prescriptions

Missing Signature Log

DATA ENTRY

Over-billed Quantity 

Refill Too Soon

Incorrect DAW Code

DISPENSING

Missing/Invalid Signature Log

  

CoPay Collection has to match Day Supply Dispense

Proof of Dispensing / CoPay Collection

Non-FDA approved medication or devices not covered by insurance

DAY SUPPLY

Insulin & Test Strips

Topicals

Inhalers

Eye Drops

REFILL RECOUPMANTS

Billing accuracy is vital day's supply of prescriptions is vital for a pharmacy. There are various situations that can make this task difficult. Medications available in one size or in unbreakable packaging may be more than what a patient during the required plan limit. Refilling a prescription too soon can be the result of claims dispensed for a plan limit.

The PBM only sees the days’ supply submitted on the claim. Once a prescription is audited, the directions for use will reveal the true days’ supply. Pharmacies must be diligent in monitoring refills for claims submitted for a plan limit but will last the patient longer.

These claims are an easy target for audit as the PBM already received the initial/rejected claim days’ supply (suspected as the true days’ supply) and a subsequent claim with a shortened days’ supply (to meet plan limits).

Based on this information, the PBM will audit subsequent refill too soon occurrences with a high margin of success.

Examples of prescriptions that pharmacies may need to dispense over the plan limit