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The Academy has released Model Audit Guidelines for Pharmacy Claims – a resource that will fulfill a significant need in the pharmacy arena and address a challenge between the community and managed care pharmacy practice.
The document is available online at www.amcp.org/audit.
The 21-page Model Guidelines document was developed collaboratively by a diverse group of pharmacy stakeholders. It is designed to help managed care organizations (MCOs) develop an effective pharmacy claims audit program, while helping pharmacists to better understand audit requirements and processes.
“We are proud to have played a key role in bringing forth this resource that will help various parties involved in the pharmacy claims process,” said AMCP CEO Edith A. Rosato R.Ph., IOM. “These Guidelines provide very practical recommendations for managed care organizations and community pharmacies to ensure a smooth process for everyone.”
The Model Audit Guidelines for Pharmacy Claims includes the following sections:
- The Role of Audits;
- Fraud, Waste and Abuse;
- Data Entry and Documentation;
- Philosophy and Responsibilities;
- The Audit Process;
- Description of Audit Types;
- Audit Process: Outline of Procedures;
- Concurrent Daily Review Audits;
- Desktop Audits;
- In-Pharmacy Audits;
- The Appeal Process;
- Compounded Medications — General Discussions and Guidelines;
- Long Term Care — General Discussions and Guidelines;
- Privacy Concerns;
- State and Federal Oversight;
- Pharmacy Audit Transaction Standard; and
- Glossary
The Guidelines stem from AMCP’s establishment of the Community Pharmacy Outreach Advisory Council in 2009. The Council is designed to address common issues between managed care pharmacy and community pharmacy as a means to enhance the relationship between the practices. The Guidelines were developed over a year by taskforce comprised of pharmacists and others from MCOs, community practice, law, auditing administration, third party management, and network administration.