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June 30, 2020
Importance of Having a Defense Lawyer During a Prime Therapeutics Pharmacy Audit
If Prime Therapeutics is your pharmacy benefit manager (PBM) and you are facing an audit, it is imperative that you obtain a defense lawyer. Detailed and invasive audits are routinely conducted by PBMs to assess whether contracted pharmacies are in compliance, both contractually and legally.

The aim of audits conducted by Prime Therapeutics is to pinpoint errors that may result in retractions, which can lead to recoupment for private payors or Medicare. This is precisely why pharmacies must have a knowledgeable defense lawyer that can provide guidance. Our experienced lawyers assist pharmacies with mitigating the issue of retractions. We also provide guidance to prevent other penalties associated with a PBM audit.

Issues That May Cause Retractions and Various Other Penalties

Embarking upon an audit by Prime Therapeutics requires you to have a strategy. You must understand the Prime Therapeutics Pharmacy Audit Recovery Guidelines and Prime Therapeutics Part D Pharmacy Audit Guidelines. These comprehensive instructions promote the recovery of payments that do not have proper documentation or are otherwise illegitimate. As a result, it is critical to demonstrate compliance, particularly as it relates to billings.

Specific issues found in the aforementioned guidelines include Dispense As Written (DAW) Error, which is issuing a brand name when there is no indication that a brand name was ordered. A Billing Error can involve not submitting an accurate metric quantity or classifying a non-compound claim as compound. No Prescription Order Provided is failing to provide a copy of the order when requested during the process of an audit. Claim Ineligible for Medicare Part D is when a member is in a long-term care facility and ineligible for Part D.

In addition to the examples provided, other potential issues are as follows: Incorrect National Drug Code (NDC) Submitted, Incorrect Location Code, Invalid Origin Code, Excessive Quantity Dispensed, Prescription Splitting, No Proof of Delivery Confirming Receipt and Quantity Dispensed Exceeds Prescription Order.

Prime Therapeutics Recovery Audit Preparation

Given the wide range of issues that can arise during a Prime Therapeutics audit, it is always best to prepare in advance. The preparation process should commence immediately after being contacted regarding an audit. This includes ensuring you have clear internal policies and procedures. Below are examples of what the preparation process should involve:

Internal Assessment: As a general rule of thumb, it is a wise business decision to conduct periodic assessments of internal systems and documentation to ensure everything is in order. This is a process that can help you identify widespread problems and resolve issues before they are identified during an audit. In the event that you are notified of a pending Prime Therapeutics audit, an internal assessment will become a top priority. The purpose of this process is to identify any issues that auditors are likely to find. This will provide you with an opportunity to resolve the problem and prevent future occurrences.

Documentation Review: Reviewing required documentation will enable you to ensure that it actually exists. There are a number of documents involved, such as prescriptions submitted electronically and refill authorizations. Any document needed to support your billings should be identified and reviewed carefully to ensure compliance.

Issue Resolution: In the event that an issue is identified during the preparation process, it is necessary to carefully consider how to address the problem. If a resolution is available, that should take place immediately. If there is no possible resolution, a decision must be made regarding what details will be disclosed. The aim is to avoid unnecessary penalties. This is a decision that should be made in consultation with an experienced defense lawyer.

Audit Response Planning: How will you handle the logistics of a Prime Therapeutics audit? This must be carefully considered. You must be proactive and strategic throughout the process. A lawyer can provide guidance on what should and should not happen during the actual audit. This includes a clear strategy for responding to any allegations made.

As you can see, there is a lot involved in a Prime Therapeutics audit. This is a matter that should not be taken lightly. Our defense counsel can provide you with assistance to handle each step in the audit process. This will position you to secure the best possible outcome for your pharmacy.



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