Common Audit Triggers :
Claims selected for review must be supported by:
- A valid physician's order authorizing the dispensing of the medication, and
- Evidence that the medication was dispensed in accordance with the physician's (prescriber's) order, state and federal guidelines, contractual requirements, and within the benefit plan guidelines.
Wattasmattau Pharmacy Benefits Management Company's on-site auditing process includes a systematic review of the pharmacy's claims history. Specific claims to be reviewed are selected by algorithms, which identify claims that meet specific criteria. Claims may also be selected subjectively by the auditor for any number of reasons including the presence of unusual trends. Claim may be chosen for audit based on, but not limited to, the following criteria:
- High dollar claims
- Quantity change within a prescription number
- High volume of claims per member
- High volume of controlled substances
- Unusual or unlikely drug combinations
- Apparent high dose
- "Doctor DAW" code claim submissions
- Compliance with FDA Risk Management Program requirements
- Quantity dispensed is within plan limits
- High number of refills
- Compliance with State and Federal laws and rules
- Amount paid for compounds is appropriate
- Random Claims
Discrepancies identified during the audit include, but are not limited to:
- Insufficient directions (e.g. UAD)
- Missing prescription
- Overbilled quantity
- Generic dispensed, brand billed
- Different drug billed
- No Signature Log
- Cut quantity
- Inaccurately billed compound
- Invalid prescription
- Wrong directions on dispensed prescription
- Invalid use of DAW codes
Wattasmattau Pharmacy Benefits Management Company has the right to assess a full recovery of the amount paid for any claims in question.
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