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Pharmacy Compliance Humana Audit Defense Lawyers

July 2, 2020

Humana makes up one of the largest Pharmacy Benefit Managers in the United States. The entity runs a large scale auditing operation to ensure that all the pharmacies under its wing are fully compliant with every statutory and contractual obligation.

Humana is a private body. It, however, partners with Medicaid and Medicare in many respects. Humana not only audits the operations of all its contracted pharmacies, but it also has the authority to impose various penalties on any pharmacy it reckons is non-complaint.

The audit process undertaken by Humana is anything but transparent. Most times, pharmacies don’t get any warning of a Humana audit. Additionally, the entity provides little to no warning about any penalties such as termination of contracts or hefty fines it is about to impose on a non-compliant particular pharmacy.

Humana Audit Consultants and Lawyers

At NYC Criminal Lawyers, we maintain a network of experienced lawyers and consultants who can effectively represent you and your pharmacy concerning anything compliance. If you feel a Humana audit is imminent, it is advisable to seek legal help from experienced professionals.

Our pharmacy defense attorneys are experienced in handling compliance and Humana audit cases. We put our vast experience into dealing with Humana auditors effectively to protect your pharmacy from any penalties.

8 Audit Terms As Identified By Humana

The Humana PBM contract stipulates that an auditor from Humana or a third-party organization assigned by any government agency or Humana can conduct audits of the pharmacies contracted by Humana on the records and prescription files with respect to services the pharmacies render to its members.

The following objectives make up a list of the types of issues that can lead to a pharmacy receiving penalties or termination:

1. Giving Out Unauthorized Refills

Before dispensing any refills to a patient, a pharmacist must determine whether the refill is physician-approved or not. Additionally, the pharmacist should take the necessary steps to determine if the situation is a medical emergency or not to warrant a refill.

Any pharmacy found dispensing unauthorized refills, refilling a patient’s medicine before the previous prescription is over, or giving our excessive refills can be penalized in a Humana audit.

2. Dispensing Incorrect Prescriptions

A pharmacist should exercise plenty of action when dispensing any medication to a member. Incorrect medicine dispensation can create serious issues not only for the patient but also for the pharmacy on all fronts.

If the auditors realize that your pharmacy has benne issuing incorrect medicine to its customers, you risk severe penalties.

3. Billing The Incorrect Payer

Billing errors make up the most common causes of terminations in Humana audits. If a pharmacy is found to have billed the wrong insurer or billed a private insurer instead of Medicaid, the mistake can bear serious consequences.

4. Billing The Wrong Doctor

Billing the wrong doctor can also bear severe consequences during a Humana audit. If your pharmacy is found to have received payment for unlawful referral fees, Humana auditors can flag the mistake and are more than likely to open a federal investigation against you.

5. Dispensing The Wrong Amount Of Prescription Drugs

Wrongly calculating the supplies of prescription medicine for a day can seem like an honest mistake. However, Humana auditors don’t take it lightly. To avoid facing penalties for such, your pharmacy should keep clear and detailed records aligning with every drug dispensed to a patient and the number of dosages dispensed.

6. Overbilling

As mentioned above, billing errors present substantial risks to any pharmacy owner. Even when the mistake is unintentional, Humana auditors can flag down any overbilling errors which can pose severe liability risks for any pharmacy.

7. Inadequate Recordkeeping

Pharmacies usually store plenty of information regarding their patients and doctors. A pharmacy must maintain detailed records and documents regarding prescription medication and controlled substances.

Failure to efficiently maintain proper record keeping can be a red flag for Humana auditors and may attract serious liability risks for your pharmacy.

8. Misusing the Dispense-As-Written codes

DAW codes provide specific guidelines to pharmacies regarding every patient’s prescription. Specific DAW codes can influence prescription drug pricing. Humana auditors are usually wary of such codes, and if found incorrectly using these codes, you could face penalties.

If your pharmacy is at risk of a Humana audit, seeking legal counsel immediately may be what you need to mitigate any risks arising from the review. Give us a call to get your case evaluated by professionals.



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