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Where oh where did my reimbursements go? Today’s pharmacy audit landscape

BY Paul Hooper

There is no doubt about it. Pharmacy audits can be time consuming and laborious for all parties involved. And as both government and commercial money gets tighter and tighter, all of health care is searching for the most effective means to manage the financial challenges associated with doing business. In addition to the clinical aspects, audits are used to identify genuinely fraudulent or erroneously paid healthcare claims. Nevertheless, a survey released in September 2012 by the National Community Pharmacists Association found that nearly 87% of those surveyed stated that reimbursement and auditing practices are “significantly” or “very significantly” affecting their ability to provide patient care and remain in business.

As audits continue to rise, more and more pharmacies are finding it increasingly important to identify possible situations and trends that might help them legitimately reduce their exposure to auditable situations. One method is to properly determine a prescriber’s eligibility before the claim is submitted to payers for processing and the prescription is dispensed. According to Emdeon data, a sanctioned prescriber could write more than 400 prescriptions per month, totaling more than $30,000 in at-risk drug costs. That could mean almost $400,000 of financial exposure to a pharmacy in a year from just one ineligible physician.  Some doctors write a lot more prescriptions than these numbers.

Pharmacies can help mitigate audit risk by incorporating improved prescriber management into their workflow. Utilizing real-time methodology, such as prescriber eligibility alerts, can not only help pharmacies lessen the audit risks and financial penalties associated with submitting prescriptions written by prescribers who do not have prescribing authority, but it can also reduce administrative costs by decreasing the time personnel may otherwise spend researching prescribers and plans. Real-time screening can be greatly improved by accessing the most current federal and state prescriber data available. Prescriber eligibility alerts can provide an advanced validation component that is able to check each submitted pharmacy claim in real time for licensure, status, sanction, DEA prescriptive authority and other issues. Rejected claims return compliance notifications with clear messaging that identifies the reason for rejection.

In addition to prescriber eligibility, pharmacies also can help protect against audits by determining appropriate patient eligibility. Pharmacy claims can be billed as primary to state Medicaid plans if, and only if, patients have no other active coverage. Consequently, pharmacies that submit claims to Medicaid for patients who are covered by other plans can be billed or penalized by the state for paid Medicaid claims.

Here are five things a pharmacy should be aware of when they are examining means to manage audits:

  1. During an audit, the scope of the claim review can cover up to three years retrospectively. Pharmacies should implement controls today to reduce the risk of potential audits tomorrow.
  2. An audit performed by the Centers for Medicare and Medicaid is contracted to a recovery audit contractor. The purpose of a RAC audit is to identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program.                     
  3. RAC audits review claims prescribed by an excluded or ineligible provider. Several third-party and private payers are adopting the same excluded provider provisions and audit criteria.
  4. According to the NCPA survey, 3-in-4 pharmacists (76%) responded that audit requirements across Medicare Part D plans are not consistent, increasing their compliance burden.
  5. Pharmacies can participate in forums to discuss and collaborate with their peers who have completed an audit.

At the end of the day, healthcare stakeholders on all sides want to see an efficient healthcare system. Healthcare payers want to ensure they are paying valid claims, and pharmacies want to dispense accurate, legitimate medications from eligible prescribers to qualified patients.


Paul Hooper
Emdeon VP of pharmacy network services
As VP of pharmacy network services at Emdeon, Paul Hooper directs the company’s pharmacy network services initiatives with a focus on developing programs, standards and partnerships that increase pharmacy efficiency and reduce healthcare costs. Paul has spent more than 25 years in the healthcare industry with a predominant focus in pharmacy. During this time, he has held roles in product development, systems, finance and operations at various recognized industry leaders: BASF, Abbott Laboratories, Cardinal Health, ArcLight and Emdeon. He holds a master's degree in business administration from Ohio University and a bachelor of science in food science from The Pennsylvania State University.

 

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Study: Most physicians support employer weight-loss programs, unhealthy food regulations

BY Alaric DeArment

ARLINGTON, Va. — More than three-quarters of physicians think the federal government should regulate foods with unhealthy ingredients, while 79% say employers should fund weight-loss programs for employees, according to results of a survey presented Tuesday at a diabetes conference.

The survey, conducted by Joslin Diabetes Center and healthcare research firm WorldOne, included more than 150 endocrinologists and primary care physicians, and results were presented at Joslin’s Diabetes Innovation 2012 conference.

"These results are very important to us and our mission," Joslin executive director of diabetes innovation and global professional education Julie Brown said. "With Diabetes Innovation 2012, it’s vital that all stakeholders are aligned, and we understand beliefs and concerns that may derail progress toward a more effective system. if stakeholder groups’ concerns are not understood or ignored, we won’t realize the true cooperation we need to make any sustained, valuable improvement."

In addition to the 76% of respondents who supported federal regulations of unhealthy foods, 71% supported New York’s ban on sugary soft drinks larger than 16 oz. in public food venues. Meanwhile, 97% said individual health counseling has a powerful effect on the health of people with diabetes. Eighty-seven percent said more pharmaceutical options for the disease are needed, while 62% said devices like insulin pumps, monitors and implants and drug therapies are most likely to have the greatest near-term benefit to patients.

At the same time, there were significant differences between the responses of physicians and delegates to the conference. While 55% of delegates said pharmacists should be able to serve as primary care providers for people with diabetes, 15% of physicians said the same. Meanwhile, 70% of physicians said pharmaceutically assisted innovations are necessary for obesity management, compared with 45% of delegates. Seventeen percent of physicians said future screening would have a positive effect on clinical outcomes; 9% of delegates said the same.


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HR programs drive employee engagement

BY Antoinette Alexander

Employee engagement and customer experience. These are not just buzzwords or empty promises for Walgreens. 


For the human resources team within Walgreens, this means attracting, training and retaining the right talent, who not only will be actively engaged but who, in turn, will enhance the customer experience in stores, whether it be in pharmacy, beauty, fresh food or any other aspect of the business.


“Our vision [is] helping people get, stay and live well, and to further that we certainly need the right talent pool to be able to support all of the business’ strategies,” said Kathleen Wilson-Thompson, SVP and chief human resources officer at Walgreens. “The progress we’ve made over the last few years in the HR department was the product of true teamwork in action. We are very deliberate in driving change that supports our business and our leadership.” To help support this vision, Walgreens is bringing its pharmacists out from behind the counter so they can provide more counseling to patients and offer clinical services. To further enhance the customer experience, the retailer also is implementing Health Guides as part of its Well Experience concept rollout. These Health Guides are Walgreens team members who are armed with an iPad and are available to answer product and service questions, help customers navigate the store and their healthcare options, and sign up for health-related events. 


“With this increased demand on talent, we know that we need to further our technology, and so we’ve been partnering with [CIO] Tim Theriault’s team … and they are supporting us as we go through an HR transformation. We are also ensuring that we have technology to have a mobile work force because we are advancing our role in health care beyond just traditional pharmacy,” Wilson-Thompson said.


For example, as Walgreens was preparing to set up its new Well Experience stores in Indianapolis, it created a full training center that replicated a pharmacy in order to enable the pharmacists to work with the new technology, conduct practice consultations and engage in other key 
consumer experiences. 


To help drive employee engagement, Walgreens developed an internal quantitative and qualitative program to help discover new ways to drive greater engagement and better understand what is most important to its associates.


“We do have data that indicates that, year-over-year since we’ve had a focus on employee engagement, our most engaged managers have been able to grow total pharmacy sales in [their] stores: front-end sales, private-label sales and even total transactions,” Wilson-Thompson added.


Meanwhile, as the nation readies for the influx of some 32 million newly insured Americans under healthcare reform, Walgreens is taking steps to ensure it is ready for the transition. As part of the effort, Walgreens recently hosted its first Chief Human Resources Officers Summit on health care. The event brought together more than 20 organizations from across the country to engage in a roundtable discussion on healthcare reform. To better understand the role that Walgreens can play to curb healthcare costs and improve employee lives, the event included a tour of the Walgreens Healthy Living Center at Walgreens corporate campus in Deerfield, Ill. 


She noted that Walgreens also tracks accountability for health metrics and has a benefit design in place that incentivizes employees to use its Take Care Clinics, versus such higher-cost alternatives as emergency rooms, and to take a proactive role in living a healthier life through, for example, getting health screenings and immunizations.


“This year, we will be able to show … that we can affect an overall reduction in healthcare costs for those folks who have participated in all of our programs,” Wilson-Thompson added.


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