Audit

Audits of Pharmacy Providers

Policy 1103

12/01/2011 Introduced
10/01/2012 Reapproved

Audits serve two main purposes: 1) detecting fraud, waste and abuse, and 2) validating data entry and documentation to ensure they meet regulatory and contractual requirements. The audit process should be transparent and have a fair design and implementation. The managed care organization should supply the pharmacy provider with a document that defines the requirements on which it may base an audit. The actual audits should be conducted in a manner that leads to continuous quality improvement of the services of the provider, rather than as a source of revenue. Further, the provider must review and be comfortable with these documents before it agrees to a contract. It is imperative that pharmacists-in-charge, and their staff, understand the dispensing and billing requirements and the implications of non-compliance. A bilateral professional level of performance can make the audit process run smoothly, be educational and improve quality.

(See AMCP Model Audit Guidelines for Pharmacy Claims).