Keystone Health Plan East, random pharmacy insurance audits for medicare/medicaid. Scary, extensive, and expensive.

by | Aug 3, 2022 | Firm News |

Are you a pharmacy benefits coordinator?  Do you run your own independent pharmacy.  Have you received a letter from KHPE, suggesting its is doing a random audit of medicaid patient expenses?  Have you received a letter request all of these below items for a a period of three years for a sample of 10 pharmacy clients?  Call me to discuss this type of audit.

Please provide the following items, in reference to the prescriptions identified below:

1.A legible photocopy (front and back) of the original prescription or physician’s order sheet, if LTC, and a reprint of the prescription label provided to the patient on the date filled;

2.A photocopy or electronic record of showing proof of counseling;

3.A photocopy or electronic record of showing proof of payment of copay, if applicable;

4.A photocopy or electronic record of the signature log (original and any refills);

5.A photocopy or electronic record of signed delivery logs or tracking sheets from internal or external delivery vendors, and any other supporting documentation that confirms delivery (original and any refills), if applicable;

6.A photocopy or electronic record of any notes concerning prior authorizations, overrides, and/or request for early refill;

7.Documented government ID for controlled prescription claims;

8.Record of a member calling and asking for refills or record and signature authorizing automatic refill;

9.Please include the Sample # from the prescription review list, below, identified on your copies.

10.Patient Profile for all drugs for each recipient contained in the below samples from 01/01/2019-current.