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pharmacy compliance optumrx audit defense lawyers

July 2, 2020
The Value of Defense Counsel During an OptumRx Pharmacy Audit
Pharmacies are routinely audited by OptumRx to address any deficiencies in compliance that may exist. While this is a common occurrence, it should not be taken lightly. It is of critical importance to ensure appropriate engagement during an audit from a pharmacy benefit manager (PBM). This is best accomplished with the assistance of experienced defense lawyers.

OptumRx audits are rigorous and invasive. If a pharmacy is unable to present the documents required to achieve compliance, significant penalties may be assessed. If you have been notified by OptumRx of a pending audit, our knowledgeable team can provide counsel to guide you through the process.

What to Expect During the OptumRx Audit Process

During an OptumRx audit, pharmacists-in-charge, pharmacy owners and other authorized administrators will be required to provide documents requested by auditors. How you respond to these requests is important. If you are in compliance, yet unable to provide the information requested, the outcome may not be positive. Pharmacies must be able to demonstrate contractual and legal compliance as outlined in the PBM contract.

Given the pervasive nature of an OptumRx audit, pharmacy administrators must be careful not to provide information beyond what is requested. Disclosing some details can be detrimental and cause unintentional results. In some instances, documents intended to demonstrate compliance result in a finding of non-compliance. Our experienced defense team can provide counsel concerning how to respond to minimize the chances of an undesirable outcome.

Issues That Can Result in Penalties During an OptumRx Audit

Receiving notification of an OptumRx audit is an occurrence that must be taken seriously. It requires you to be proactive and ensure due diligence. There are many objectives associated with an audit. One goal is to find instances in which a pharmacy has engaged in overfilling for prescription drugs. This is a finding that can result in a retraction, among various other penalties. Here are examples of issues that might cause this outcome:

Insufficient Proof of Staff Training: Pharmacy staff must receive training on compliance, which often covers fraud, Medicare billing and drug diversion, among other topics. You must ensure all required training is conducted. You must also ensure training is documented. Penalties are possible if you have a program without proof that training occurred.

Licensing Non-Compliance: Every pharmacy must possess proper licensing. If your license has expired, OptumRx auditors may claim that billings submitted are invalid. Failure to present the required licenses can also become a problem. Licensing non-compliance can result in retractions and other penalties.

Prescription Filing Errors: Penalties are likely when a pharmacy dispenses too much medication or the wrong prescription. This can occur when the medical necessity of a drug is not verified. This issue is combatted by ensuring clear and thorough documentation at all times.

Billing Errors: Errors in coding and billing are problematic during an OptumRx audit. This is especially problematic when billing Medicare. Even unintentional mistakes can result in retractions and other penalties.

These are just a small sampling of problems that can arise during an OptumRx audit. Our defense lawyers can assist you with obtaining a more comprehensive understanding of issues that can result in penalties.

Proactive Measures to Take During an OptumRx Audit

To mitigate the risk of retractions and other penalties, you must maintain a proactive approach before and during an OptumRx audit. One step you can take is identifying whether your pharmacy is at risk. This is often determined by assessing the quality of your documentation. This includes reviewing documents for errors. If you find mistakes, they must be resolved promptly. If you are unable to identify a resolution, a decision must be made concerning how to address the problem to avoid severe penalties.

Chief among the steps that should be taken upon being notified of an OptumRx audit is developing a strategy for how you will respond to inquiries and issues that arise. Although OptumRx is conducting the audit, you should not relinquish control. How you provide the information requested must be strategic.

Whether you have been contacted by OptumRx regarding an audit or you simply want to learn more about the audit process and common mistakes, our experienced team of defense lawyers are here to help. Preparation is imperative to achieve desired outcomes.

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