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Wattasmattau Pharmacy Benefits Management Company
New Auditor Help Center
Definition of the Types of Audits & Audit Procedures :
 
The auditing of pharmacy claims serves two main purposes:
  1. detecting fraud, waste and abuse
  2. validating data entry and documentation to ensure they meet regulatory and contractual requirements.

Audit Types: There are different types of audits that apply to pharmacy claims or conducted by Wattasmattau Pharmacy Benefits Management Company:
 
Concurrent Daily Review: An audit that is conducted by telephone or email usually immediately (within the same day but no longer than 72 hours of claim submission). The claim concern is usually resolved at the time of notification by the pharmacy's electronic resubmission of the claim.
 
Retrospective Audit: An audit that is a retrospective detailed analysis of the total volume of claims submitted by a pharmacy. A retrospective audit can be conducted using one of three types of pharmacy claims auditing:
 

 
Desk Top Audit is conducted after notification by Wattasmattau Pharmacy Benefits Management Company to the contracting pharmacy as defined in the contract between the parties. The audit is conducted electronically. Desk audits use automated means to review pharmacy claims and encounter data. This type of audit can include reviews of payment reports, drug utilization, physician prescribing patterns, and geographic prescribing reports.
 
Procedure - Desk Audit
  1. Notification(Pre-Letter) of the audit is sent to the pharmacy or corporate office with a list of prescriptions and signature verifications requested for the desk audit.
  2. Confirmation calls are made to the pharmacy three days prior to the deadline for submission if Wattasmattau Pharmacy Benefits Management Company has not received documentation from the pharmacy.
  3. Prescriptions and signature verifications are reviewed by an in-house auditor;
  4. The Post Audit Letter and Preliminary Audit Report are sent to the pharmacist with the results of the desk audit. The preliminary report includes claim level details on any audit discrepancies, a description of the discrepancy and documentation that may be submitted to mitigate the discrepancy, if any. The auditor will schedule a call with the pharmacist to review the preliminary report and discrepancies identified. The Post Audit letter supplies the pharmacy with 30 days to supply supporting documentation for the discrepancies found.
  5. The Final Letter and Final Audit Report are sent after/during the 30 day window supplied in the post letter has expired. This letter includes a Final Audit Report detailing any remaining discrepancies and allows the pharmacy 30 days to appeal the audit directly to Wattasmattau Pharmacy Benefits Management Company. Instructions and contact information for Wattasmattau Pharmacy Benefits Management Company are included in the letter.
  6. Overpaid claims are gross adjusted and will be reflected on a subsequent pharmacy remittance advice.
  7. Wattasmattau Pharmacy Benefits Management Company may require a Corrective Action Plan (CAP) from the pharmacy documenting the changes that the pharmacy will put in place to prevent the same discrepancies from occurring in the future. The CAP should be sent to Wattasmattau Pharmacy Benefits Management Company.
  8. Wattasmattau Pharmacy Benefits Management Company will follow up within 6 months of approval of the CAP to ensure the pharmacy has implemented the changes and is in compliance with the CAP.

 
Pharmacy Audit (field audit) is conducted after notification by Wattasmattau Pharmacy Benefits Management Company to the contacting pharmacy via email, U.S. mail, or other channel as defined in the contract between the parties. This audit is conducted onsite in the pharmacy. A Pharmcy Field Audit usually involves physical observations, prescription reviews, and checks for compliance with Wattasmattau Pharmacy Benefits Management Company regulations and procedures. Field auditors will typically review the following:
  • Prescription records
  • Computerized dispensing records
  • Patient signature logs
  • Quality control plans

Procedure - On-site Audit
  1. Notification(Pre-Letter) of the audit is sent to the pharmacy 14 calendar days in advance of the scheduled audit stating date of arrival.
  2. Confirmation calls are made to the pharmacy three days prior to the scheduled onsite audit to confirm the date and provide the time for the audit
  3. The auditor will arrive at the pharmacy to perform the onsite audit. A sample of the items to be reviewed during the site visit are:
    • Prescription sample review (written and electronic)
    • Signature logs
    • Will call bin
    • Pharmacy's written policy and procedures for reversal of not picked up prescriptions.
  4. The auditor will make scanned images of the documentation reviewed on site.
  5. The auditor will be onsite at the pharmacy for approximately 3.5 to 4 hours; however, if necessary the auditor may extend his/her visit to 6 hours.
  6. At the conclusion of the site visit the auditor will provide the pharmacist with an exit report containing a list of any missing documentation and the types of discrepancies identified. The pharmacist signs the exit report indicating the auditor reviewed it with them and a copy is provided to the pharmacist.
  7. Following completion of the site visit the audit is reviewed by an in-house auditor and a preliminary report is generated.
  8. The Post Audit Letter and Preliminary Audit Report are sent to the pharmacist with the results of the onsite visit. The preliminary report includes claim level details on any audit discrepancies, a description of the discrepancy and documentation that may be submitted to mitigate the discrepancy, if any. The Post Audit letter supplies the pharmacy with 30 days to supply supporting documentation for the discrepancies identified in the Preliminary Audit Report.

 
Investigational Audit is broader than a pharmacy claims audit and may be initiated from a medical, dental or another type of claim. An investigational audit is usually a more extensive audit and can involve regulatory and law enforcement. Typically this type of audit commences when there is clear evidence based upon preliminary reviews or audits that reveal fraud or abuse by patient or provider.

 
Failure to Respond to Audit Results
Failure to respond to any audit by the initial due date (unless an extension is granted prior to the due date) will result in assessment of a penalty as follows:
 
If documentation is received: Prior to the audit deadline
Penalty assessed will be: None
 
If documentation is received: After the audit deadline but before the post audit deadline
Penalty assessed will be: 25 percent of the total value of the audited claims
 
If documentation is received: After the post audit deadline
Penalty assessed will be: 100 percent of the total value of the audited claims