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Taming the Medicare Audit Beast: Three Ways to Improve Your Pharmacy’s Outlook

BY Deborah Roberts
There are few things that rock a pharmacy manager’s world like a Medicare Part B Audit, and the likelihood that an audit request will be received is increasingly high.
 
Efforts by the Centers for Medicare and Medicaid Services to address “fraud, waste and abuse” has resulted in the introduction of numerous Medicare contractor programs. From a variety of audits, including Medical Review and RAC to CERT and ZPIC, resource-strapped pharmacies must now navigate complex processes and stringent Medicare requirements.
 
It’s a mammoth undertaking, and the reality is that internal management strategies often fall short of readiness and compliance. The resources required to successfully maintain up-to-date documentation practices as well as respond timely to audit requests are simply a non-starter for many pharmacies. 
While some pharmacies choose a hybrid approach that leverages both in-house and external expertise, the best strategy is characterized by engaging a strong partner for end-to-end management of audit responses. The right framework of technology and expertise can improve the outlook on Medicare Audits in the following ways.
 
1) Improve front-end processes
Pharmacies are best positioned for a Medicare audit when they take a proactive approach to documentation and claims on the front-end. Solutions exist to ensure documentation templates are updated to reflect the latest Medicare requirements and identify potential issues before a claim is submitted.
 
For instance, small details such as the legibility of physician signatures can warrant a denial. When a pharmacy is leveraging the expertise of a strong partner, there is proactive management of signatures and other details on the front-end to ensure compliance. Without this framework, pharmacies might otherwise have to hire staff to address the nuances of ever-changing Medicare requirements and implement formal education programs.
 
2) Timely and appropriate response 
Pharmacies often struggle with responding in a timely manner to audits due to difficulties identifying if a request has been received. Consider a large pharmacy chain with corporate and accounting offices across the United States, for instance, and the challenge that presents to correctly identifying and managing a request for audit. 
 
Also, because Medicare audits are usually complex and resource intensive, some pharmacies choose to ignore requests, which may potentially allow earned dollars to go back to the payer. The rationale for that decision often rests with the belief that it will cost more to take the time to work an audit than to lose the money.
 
This practice is not prudent for a number of reasons. First, pharmacies want to keep a solid record of compliance to reduce the potential for future audits—and response is part of that equation. Second, pharmacies might be allowing earned dollars to be recouped by the payer when there are legitimate reasons to retain that money
 
When the right technology and partner are engaged, pharmacies can streamline processes to enable prompt identification of audit requests and timely responses. 
 
3) Ongoing Quality Improvement 
When audit management activity is automated and centralized, greater opportunities exist to identify areas for improvement. Pharmacies can leverage data from robust analytics platforms and expert analysis and thereby improve feedback and education for the pharmacy. 
 
Audits are inevitable in today’s healthcare climate. In preparation, pharmacies should consider following these key partner strategies to improve front-end processes, enable timely response to audits and provide the visibility needed to improve performance going forward.
 

Deborah Roberts is Change Healthcare’s Manager Recovery and Audit, CMS Compliance. 

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Walmart challenging Amazon with shipping offer

BY Dan Berthiaume
The world's largest retailer is throwing a counterpunch to Amazon's Prime service. 
 
Walmart is offering a free 30-day trial of its ShippingPass program, which offers consumers  unlimited, two-day free shipping for a year.  Normally, the service costs $49 per year.   (So as not to feel left out, existing ShippingPass members will receive a free month of the service).
 
In addition, starting July 1, Walmart promises to begin offering special online rollback prices which will last 90 days or more. The retailer is promoting the price breaks as being in honor of the upcoming Independence Day holiday, but the timing certainly gives it a running start against upcoming Prime Day deals.
 
ShippingPass costs about half of the $99 annual Amazon Prime membership fee, with customers trading one day of shipping for a lower cost. However, Walmart has the advantage of fulfilling from its network of thousands of local stores, as well as not offering other digital features of Amazon Prime such as content streaming.
 
Walmart’s online shipping program has no minimum requirements for number or cost of items ordered and also accepts free returns. Much like Amazon’s secrecy around the performance of Prime, Walmart has so far not broken out details about ShippingPass metrics.
 
In addition to offering its own July online sales event, Walmart has also treaded on Amazon’s turf by providing online grocery delivery and free cloud hosting services, as well as by testing delivery drones. In 2015, Walmart competed with the hugely successful Prime Day event by lowering the minimum order for free shipping from $50 to $35 and lowering online prices for thousands of items. The discounter is upping its game this year, although Amazon has not released specifics about the latest iteration of Prime Day and may have a few tricks up its sleeve.
 
The ShippingPrice promotion and online discounts will be available on both the Walmart e-commerce site and mobile app. In a corporate blog post, Walmart also promised it has “some other ways we’re going to connect our app, site and store for customers in the coming weeks.”
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Clinics pop up in regional chains

BY Richard Monks

There is no clearer evidence that retail clinics have become a vital component of community pharmacies than the recent proliferation in smaller, regional chains.

(To view the full Category Review, click here.)

“The industry data out there supports consumer acceptance of the in-store clinic model, whether it has convenient locations, flexible hours or the flexibility of accepting walk-ins,” said Pete Ratycz, VP pharmacy at Discount Drug Mart, which last fall opened five clinics in partnership with Cleveland-based MetroHealth. “Combine that with the benefit of processing a prescription — and quickly processing that prescription — and it’s no surprise that there’s been rapid adoption of the concept.”

“Access to convenient and affordable healthcare services is more important to [customers] now than ever before,” added Hy-Vee SVP pharmacy operations Kristin Williams when speaking about the company’s decision to continue to build on its base of 30 clinics.

Many regional players of all sizes also have begun incorporating clinics into their stores. Austin, Minn.-based Astrup Drug, for instance, has 17 stores; two with Smart Clinic walk-in health centers.

In the Pacific Northwest, Seattle-based Bartell Drugs has slowly been rolling out clinics since 2013 through a collaboration with Group Health Cooperative. Currently, the 64-store chain has five clinics and plans to add at least two more clinics this year.

Memphis-based Fred’s debuted its first health clinic last year in a store in rural Arkansas to help alleviate the primary care physician shortage in the area. Meanwhile, Fruth Pharmacy has teamed up with local healthcare provider PVH Health to open a pair of Express Care Clinics at stores in Point Pleasant, W.Va., and nearby Pomeroy, Ohio.

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