As the bell is about to ring at midnight, Scott Newman desperately feeds the pages into the scanner, trying to prevent thousands of dollars in prescription payments from turning into pumpkins.
As the owner of Newman Family Pharmacy, an independent pharmacy in Chesapeake, Virginia, he is responding to an audit ordered by the pharmacy benefits manager, an intermediary company that processes pharmacy payments for health insurance companies. The audit notice was issued in January when he was scrambling to obtain certification to provide the covid-19 vaccine, but he had forgotten that. Then, a month later, the final notice reminded him that he needed to scan and upload 120 pages of documents supporting approximately 30 prescription claims before the end of the day.
“I’m sure I will be missing pages,” he recalled. “So I’m rescanning the contents of the damn file.”
Every page is important. The pharmacy welfare manager or PBM suspended the in-person review last year due to the new crown pneumonia epidemic and switched to a virtual review, just like seeing a doctor in person and turning to telemedicine. In the case of increased pandemic pressure, this means that pharmacists such as Newman have to undertake more audit workloads. It also allows benefits managers to review—and possibly deny—more pharmacy claims than ever before.
According to the data from Public Affairs Bureau The country’s, Pharmacy audit auxiliary services, the number of pharmacy audits in 2020 decreased by nearly 14% compared with the previous year, but the overall number of prescriptions increased by 40%. This means that if the auditor can find any reason (even a minor clerical error) to refuse payment, the pharmacy will have to provide more documents and may lose more money.
PAAS data shows that the average audit cost of pharmacies in 2020 is US$23,978, which is 35% higher than the annual average of the past five years. The number of prescriptions reviewed in September and October is four times the number seen by PAAS members in previous years.
Pharmacists have long complained that audits seem to have nothing to do with eradicating fraud, waste and abuse, but rather a way for these intermediary companies to get rich.According to IbisWorld’s business analysts, the pharmacy benefit manager market in the United States has grown to nearly US$458 billion This year, 8 years ago, it was less than 300 billion US dollars.
Even before the pandemic, independent pharmacies were in financial distress for themselves due to low reimbursement rates, loss of customers to mail-order services or chain pharmacies, and various measures taken by welfare managers (including charging pharmacies and maintaining manufacturer rebates) .
Adding to the problem: Many independent pharmacies report that they have received takeover offers from large chain pharmacies that own PBM, and pharmacists believe this is the main reason for their financial troubles.
Pharmacists say that, at least, virtual audits will increase waiting time and increase customer costs. In the worst-case scenario, an audit will cause the pharmacy to pay thousands of dollars for the medications that have been distributed to customers, and may eventually bring them out of business.
“This will definitely keep pharmacy employees away from their responsibilities, which has become an administrative burden, which does have a direct impact on patient safety,” said executive director Garth Reynolds. Illinois Pharmacists Association“They must become the de facto audit team of the pharmacy welfare manager.”
PAAS National President Trent Thiede said that many of the more than 5,000 pharmacies he has worked with have stepped up to provide Covid testing and injections and become a greater resource for customers during this health crisis. “As vaccination is in full swing, the priority should be on serving patients and our community, rather than responding to audit requests,” Ted said.
When the auditors come in person, they mainly conduct the review themselves, occasionally requesting the pharmacist to provide additional documents.
“In these virtual audits, you have to take the prescription, put it in through some kind of photocopier, summarize everything, get all signed logs. They want your license to hang on the wall. They want to fax all employee licenses,” Thiede Say. “These pharmacies are much harder.”
Spokesperson Justine Sessions said that Express Scripts, one of the largest welfare management agencies in the United States, has turned to virtual audits as a security measure. She wrote in an email: “The virtual experience is very similar in scope and scale to in-person audits, and is conducted at the same frequency.” “Under safe circumstances, we intend to resume on-site audits.”
CVS Caremark and OptumRx, welfare managers belonging to the CVS pharmacy chain, did not respond to interview requests.
Dave Falk, who owns 15 Illinois pharmacies, said that the largest audit he had seen before the pandemic was for 60 to 70 prescriptions, valued at between $30,000 and $40,000. Then, last fall, his pharmacy in Robinson had to defend the $200,000 prescription in a virtual audit.
“None of these prescriptions are less than $450,” he said. “These audits are not random. This is PBM’s money-grabbing behavior.”
When the auditor asked his pharmacist to report the temperature of the perishable medicine stored in the refrigerator, he was shocked. This information has nothing to do with the appropriateness of the prescription that was dispensed a few months ago.
“They are looking for any reason to recover the funds,” Falk said.
After Falk and his pharmacist spent hours providing documents, the auditor initially rejected the $36,000 payment for the drug, mainly due to the lack of patient signatures. Like most pharmacies during the pandemic, Falk’s stopped collecting patient signatures for safety reasons last year.Major industry associations representing PBM companies and pharmacies have come Reach an agreement Last year, patients did not need to sign for medications provided via mail order, delivery, or curbside pickup.
Despite this, Falk’s staff had to track dozens of patients and have them sign an affidavit that they had received prescriptions, thereby reducing the auditor’s denial to $12,000.
“For ridiculous reasons, this is $12,000,” Falk said.
He said that in his eight years as a pharmacist, Newman has undergone six audits, but the most recent one was done in person. In a virtual meeting on behalf of the health insurance company Humana, Newman uploaded his documents before the deadline. But he was also marked as missing a signature.
Dan Strause, president and CEO of Hometown Pharmacy in Madison, Wisconsin, said his pharmacy received more than 1,000 pages of audit requests last year, covering more than $3 million in prescription claims. This accounts for 1.5% of the company’s total annual revenue. He said pharmacists last year saw a surge in what they called predatory audits, which looked for ways to deny payment for legitimate prescriptions.
“What they did in 2020 should be condemned,” Strauss said. “While we are caring for patients, they are sitting in a comfortable office thinking,’How do we make money from it? Can we find loopholes? Can we find the missing files? Can we find a reason to take things back?'”
Humana spokesperson Lisa Dimond (Lisa Dimond) said that the government requires the company to conduct an audit to see whether the pharmacy complies with regulations, but compared with 2019, there are fewer prescriptions for audits and reviews in 2020.
She said in a statement: “We have been working hard to reduce the administrative burden on our online pharmacies, providing extensions when needed, while still working hard to ensure that the pharmacies dispense our members safely and correctly.”
When a large chain of pharmacies that run their own welfare managers offer to buy their stores, pharmacists will get angry and admit that the times are difficult. Joe Craft owns the Happy Druggist chain of pharmacies in central Ohio. He said that he often received a letter requesting the acquisition of his business from the same company, causing him to lose an average of $6,000 in payments per audit, which is roughly equivalent to a week’s income of a pharmacy.
“When you read that letter, you were thinking,’Damn it, yes, times are tough,'” he said. “Of all people, they should know.”
Usually, when independent pharmacies are sold to larger chains, these pharmacies will close their doors, and the chain pharmacies will direct customers to a location a few miles away.
Thiede and many pharmacists believe that although face-to-face audits may resume after the pandemic, virtual audits may continue to exist.
Thiede said: “They can do more because they don’t have to travel and fly all over the country, and they don’t have to sit in your pharmacy all day.” “They can do and do more work at home.”
Caesars Health News (KHN) is a national health policy news service.This is a program independent of editing Henry J. Caesar Family Foundation Not affiliated with Kaiser Permanente.
Photo: Ridofranz, Getty Images
