Guideline for Pharmacy Claims Audits Could Add Consistency to the Process

Atlanta—A guideline for pharmacy claims audits could help improve collaboration and minimize friction between managed care organizations (MCOs) and community pharmacists, according to a Contemporary Issues session at the AMCP meeting. An AMCP task force has been working on developing an audit guideline goal and discussed their process, current problems with pharmacy claims audits, and their hopes for the guideline during the session.

Michael Tocco, RPh, MEd, chairperson of the AMCP Community Pharmacy Outreach Council (CPOC) and president of Integrated Pharmacy Solutions, led the presentation alongside Julie Lenhard, PharmD, chairperson of the AMCP Community Pharmacy Audit Guideline Task Force and manager of managed care for Wegmans Food Markets, Inc. AMCP formed the CPOC so that MCOs and community pharmacy providers would have an outlet to learn from one another and work more closely to provide improved patient care. One of the council’s tasks was to develop a model guideline for community pharmacy claims auditing. A model guideline could help reduce friction between MCOs and community pharmacists and could help eliminate inconsistencies in the current audit process.

According to the presentation, currently there are inconsistent contracts and rules, state regulations, and audit practices. To address the issue, the CPOC developed 3 top issues for the council. These included the need to better understand each other’s role in providing pharmaceutical care, the need to work together to identify and clarify why current audit practices are creating friction between the 2 groups, and the need to develop a diversified group of stakeholders to create the guideline. They also formed an AMCP Community Pharmacy Audit Guideline Task Force. The goal of the audit guideline was to create a guideline that created a reasonable process to conduct pharmacy claims auditing that could be embraced by both MCOs and community pharmacists.

To begin the process, the task force first identified top issues for each stakeholder group by conducting a survey of community pharmacists across the country and health plans and MCOs. They found that top concerns for pharmacies were time, inflexibility of scheduling audits, citing “frivolous” reclaims, inconsistency in the results process and among MCOs, and that risk-based auditors’ fees were linked to findings. Pharmacies also cited the need for a dispute and appeals process that had consistency throughout the industry. MCOs reported difficulties in scheduling audits, pharmacies not responding or being prepared for audits, pharmacies using the appeals process to prolong recoveries, and inconsistent prescription filings in long-term care pharmacies. They also noted a lack of compliance with state and federal regulations.

According to the session’s presenters, a model guideline would give MCOs and community pharmacies a tool to understand, develop, and operationalize their audit program to prepare and respond to an audit. The task force discovered that there were many issues that were not fully understood between the groups and there often was a lack of awareness of important issues. The group was able to reach agreeable guidelines; however, it was not an easy process, the speakers said. They identified several examples of recommendations from the task force, including a definition of the appeals process and ways to mitigate the amount of time spent on an audit. Next, the task force plans to present the guideline to the AMCP Board of Directors for approval and later provide access to it through the AMCP Web site. While they hope to continue dialogue and refinement of the process, the presenters concluded by saying that MCOs and community pharmacies can work well together to improve patient care and minimize friction between the groups.