Video instructions and help with filling out and completing Why Form 5495 Certification

Instructions and Help about Why Form 5495 Certification

Welcome to the pharmacy self-audit Inge control practices to improve Medicaid program integrity and quality module three invoice management presentation module 2 controlled substances management discussed how to incorporate an evaluation of controlled substances practices into a pharmacy self-audit steps 13 through 22 were reviewed and examined topics covered included hiring employees how to handle internal diversion controlled substances inventory management handling loss or theft and responsibilities of the pharmacist in charge the p.i see the topics of prescription drug monitoring programs PDMPs lock-in programs physical security and communications were also covered invoice management is the third component of the self audit process effective invoice management helps to detect and prevent fraud waste and abuse let's discuss the various approaches to validating wholesale invoices to better understand how invoice management affects pharmacy practice we will also discuss ways in which drug claims can exceed purchases including when drugs are obtained from illegal sources prescription drug samples are sold drugs return to stock are resold and drugs returned from institutions or patients our soul finally the discussion addresses how drug claims can exceed sales through incentives illegitimate prescriptions point-of-sale billing manipulations coordination of benefits manipulations and phantom claims let's get started by reviewing the objectives for module 3 by the end of the module 3 invoice management presentation you should be able to identify for pharmacy inventory management activities that may cause prescription claims to exceed drug purchases and recall 5 pharmacy building activities that may cause prescription claims to exceed prescription sales the audit process is a means of reviewing pharmacy practices to ensure staff members uphold operational procedures state and federal programs such as Medicaid and Medicare Part D state licensing boards the US Drug Enforcement Administration the DEA the US Internal Revenue Service the IRS and other third-party payers conduct pharmacy audits through the pharmacy self-audit tool pharmacy staff members can evaluate daily practices pinpoint potential audit triggers and proactively address vulnerabilities like any developing habit a self-audit can become part of a daily weekly or monthly task pharmacists or their pharmacy managers can customize the pharmacy self-audit to ensure the self-audit addresses all pharmacy specific compliance and operational procedures when developing the blueprint for a customized pharmacy self-audit consider the different forms of prescription drug fraud waste or abuse that may occur in the particular pharmacy setting and focus on these vulnerabilities the self audit process consists of 50 steps to help identify potential audit triggers in a pharmacy practice the audit process includes detailed information regarding each step and is divided into four subsections that can be used separately or together as appropriate to meet the needs of the pharmacy practice prescribing practices controlled substances management invoice management and billing practices each subsection is addressed in the four modules of this presentation the 50 steps described in the presentation modules correspond to the steps found on the pharmacy auditing and dispensing the self audit checklist that accompanies this presentation consider each step answer the questions listed and examine existing policies and procedures to identify any audit triggers related to prescribing practices controlled substances management invoice management and billing practices before beginning the module 3 invoice management self audit gather the following information and conduct a review of documentation purchase records invoices and claim transaction records to perform an invoice management self audit effectively first examine the numbers that appear on the invoice and compare those values with claims records drug claims exceed purchases if a pharmacy bills for more drug units than it purchased this situation is considered an invoice shortage invoice shortages occur when a pharmacy cannot reconcile its drug purchases to its sales this may be the case if a pharmacy purchases an insufficient quantity or if no record exists of a specific national drug code NDC purchase the pharmacy is at risk of overbilling insurers and federal health care programs if drug claims exceed purchases when drug orders arrive create and follow written procedures for the receipt of a drug order and the validation of the invoice written procedures set the standards for pharmacy staff members to help maintain uniformity for day-to-day operations maintain documentation of pharmacy staff members who validated the daily drug order it is important to allocate time to process invoices before the drugs are placed into inventory scrutinize the invoice and ensure you received all drugs that appear on the wholesale receipts on going on a regular basis confirm that your claims for any particular drug match the number of units of the drug purchased from the wholesale distributor and other applicable company's compare the number of units of medication purchased from wholesale distributors and other applicable company's to the corresponding number of claims for that drug compare the NDC's of medications purchased from wholesale distributors and other applicable company's to the NDC's that appear on claims for that drug if claims are greater than purchases payers including federal health care programs may suspect fraud dishonest pharmacies and pharmacists have been known to sell drugs obtained from illegal sources drug samples drugs return to stock and drugs returned from institutions or patients invoice shortages pose very real risk you and your pharmacy at best you must reimburse Medicaid or other payers for claims you cannot justify through invoice records at worst you and your pharmacy may be charged civilly or criminally may be assessed civil monetary penalties and risk being excluded from participating in any federal health care programs let's walk through each of these situations and identify any areas of Pharmacy risk only do business with reputable wholesale distributors and other applicable company's this is a critical decision requiring due diligence on your part wholesale distributors and other applicable company's must have detailed policies and procedures related to record-keeping drug origin drug storage licensure and other pertinent information the National Association of boards of pharmacy and abp accredits wholesale distributors and works in conjunction with state boards of pharmacy to help regulate the drug supply chain verified