Note from the CEO: This letter brought a smile to my face. It reminds me of all the hard work our auditors are doing everyday. Remember, any mistake, even a minor clerical error that allows us to "legally" chargeback a pharmacy claim, allows us to better serve our clients (and ourselves).
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Letter to the CEO of the Wattasmattau Pharmacy Benefits Management Company
To whom it may concern,
Community pharmacy plays a vital role in a healthcare system that is being overrun with companies
more worried about profits than patients. Now is the time to evaluate the practices of these companies.
Ganse Apothecary Inc. has been in business since 1970 and services retail and long term care
consumers. Our focus has mostly been in mental health, intellectual disability and addiction recovery.
Our radius of business goes well outside of Lancaster. We service clinics and group homes all over
eastern Pennsylvania, with focuses in Lancaster and Philadelphia.
Over the last five years that I have been involved in our family business it has been my responsibility to
endure the auditing process. This is by far the most frustrating part of my job. It takes countless hours
to perform an audit, let alone the time and money it takes to fight the results. We have had as many as
four audits in a 3 month time period. Sometimes they will ask to do 2 in one day so they don't have to
come back. That means I have to dedicate staff including myself to them for a whole day. I want to
break this down a little for you so you get the real picture of what this process is like.
The auditor (certified pharmacy tech or RPh) shows up either in the morning or the afternoon almost in
the same fashion as the cable company. We have no idea what time they are coming, just a window of
opportunity for them. We have actually had auditors show up at 5pm to start an audit when we close at
6pm and give us a hard time about rescheduling. We have also had auditors not show up at all and then
call to reschedule. Upon setting up their scanners in our office they proceed to give us a list of close to
300 prescriptions and 30 patient signatures logs that they need to see. What I find very interesting is
the formula that the audit companies use to generate the claim lists. One would think that it would be
fair to audit a random sample of claims that have been adjudicated. The formula is cost based, not
claim based and they admit to that. I have included a pre audit report page that lists the RX# and
medication they are going to audit. Please take notice that all of these medications are Brand products
with the exception of clozapine which is a very expensive generic product. Keep in mind that the
dispensing rate of generic product to brand products is close to 4 to 1, but they have no interest in
auditing those claims? Trust me, as a pharmacy that specializes in mental health, there is no shortage of
expensive claims to audit. I suspect that this formula was created because the audit companies are
being paid a percentage of the amount they "recoup" from us.
Our system is computerized, so we print a scanned copy of the prescription, but this usually takes about
3 to 4 hours to complete between 2 staff members. They check every small detail of the prescription.
Everything from date to doctor to notes on the prescription. I even had an auditor ask me for the back
label that goes on the prescription. Why that is relevant is beyond me and I told him he could go
through the hard copies as we don't scan the front and the back of the prescriptions. He declined and
said he would work around it. When they are done reviewing all of the prescriptions we are given a
summary of issues and later receive a formal communication from the auditing company detailing the
issue, the chargeback and where to send our dispute. Most of the findings that come from these audits
are bogus. They will tell us we altered a prescription or submitted the incorrect prescriber and upon
further review they rescind their findings after we provide further documentation.
There have been several times though that they will not accept our documentation and we have had to
go to the insurance company ourselves to plead our case. In one recent audit the doctor changed the
amount of refills without initialing it. The auditor caught it and requested $1700 back from us. We had
the physician write a letter admitting that it was her handwriting and that she did indeed want those
refills for the patient. The audit refused her letter and we disputed one more time. We had the
physician write another letter and again they refused it. It's too expensive to fight with a lawyer, so I am
forced to lose $1700.
In another audit we had a similar situation. The doctor wrote for a specific strength of Seroquel ($13 a
tablet) and had to retrace the strength on the hard copy because his handwriting is a little shaky. The
auditor claimed we altered the script without documentation and therefore it was invalid. We asked the
doctor to write a letter and they accepted our documentation. What is the standard of disputing
documentation when they only accept certain letters in similar situations?
We have had auditors tell us we altered prescriptions for solutions and medications that are billed based
on ml/mg only to find out what they are seeing is our pharmacists calculation that he wrote on the script
to ensure they were not being over billed based on days supply. These auditors are supposed to be
certified pharmacy technicians or pharmacists with experience in the field. How is it possible for them
to see these types of calculations and claim that we altered the prescription? Many times a doctor will
write for a total mg dose of an oral medication not realizing that the medication does not come in that
size and we need to substitute it for 2 pills of a smaller strength or 1 pill of a larger strength. The
auditors go crazy over those prescriptions, but we haven't done anything wrong.
I will give you one last example. In this example we made a mistake, but not a major one and they asked
for $6,074 in charge back. We adjudicated the claim with the wrong doctor's name. The doctor was in
the same practice and had also seen this patient the month before, but for whatever reason he saw
another doctor in the same practice and we missed it. We are human, we make mistakes. The audit
company refused all of our documentation including letters from both doctors saying they were fine
with the error. We had to call the insurance company and ask them to review the claims of the audit
company. The insurance company's audit department asked for all the documentation and said they
would review it. Within 24 hours they called us back and had manually changed the doctors in their
system to reflect the correction. If it is just that simple why are we being penalized for such small
discrepancies?
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