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Academy of Managed Care Pharmacy (AMCP) Releases Model Audit Guidelines for Pharmacy Claims

ALEXANDRIA, Va., Jan. 13, 2012 /PRNewswire-USNewswire/ -- The Academy of Managed Care Pharmacy (AMCP) is pleased to announce the release of Model Audit Guidelines for Pharmacy Claims – a resource that fulfills a significant need in the pharmacy arena and addresses a challenge between the community and managed care pharmacy practice.


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.

"Audits of pharmacy claims are a necessary function in today's health care system," Rosato added. "But they too often are clouded by misunderstandings regarding their intent and how they are carried out. These Guidelines provide very practical recommendations for managed care organizations and community pharmacies to ensure a smooth process for everyone."

The auditing of pharmacy claims serves two main purposes: 1) detecting fraud, waste and abuse, and 2) validating data entry and documentation to ensure they meet regulatory and contractual requirements. Audits remain the primary method presently available for MCOs to determine network pharmacy compliance and to identify fraud, waste and abuse within the prescription drug benefit, as these contribute to the rising cost of health care.

The audit process has become essential under the Medicare Part D program, as the federal government increases its scrutiny of pharmacy claims and billing practices. The federal standards have led to an increasing level of oversight of pharmacy claims in commercial plans as well, and are reaching into the specialty pharmacy practices associated with long term care and home infusion pharmacies.

The Model Audit Guidelines for Pharmacy Claims addresses these issues and more, and 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

Rosato noted the Model Guidelines will play an important role in helping pharmacy stakeholders understand each other's roles and responsibilities in the auditing process. "In addition, the Guidelines will ease pressure on state legislatures to move forward with pharmacy benefit auditing legislation, as lawmakers will give the guidelines time to work," she said.

The Guidelines were developed over a year by an AMCP-led taskforce comprised of pharmacists and others from MCOs, community practice, law, auditing administration, third party management, and network administration. The American Pharmacists Association, the Food Marketing Institute and the National Community Pharmacists Association also contributed to this project.

The taskforce addressed the lack of understanding from each side as to why audits are needed and complaints over how they are conducted.

From community pharmacy practice, complaints included the MCOs' requirements of time and inflexibility in scheduling audits, as well as a lack of consistency of the audit and appeals process among MCOs. From MCOs, complaints included that pharmacies didn't respond to requests for audits or were not prepared for the audit, and a lack of understanding that audits can include the pharmacy's compliance with state and federal law.

The members of the taskforce learned from each other and respected diverse views. "This exercise showed that community pharmacy practice and managed care pharmacy can come together in a positive way and tackle tough issues," said April Shaughnessy, AMCP's Director of External Affairs, who served as project staff liaison.   

The document is available online at

About AMCP

The Academy of Managed Care Pharmacy (AMCP) is a national professional association of pharmacists and other health care practitioners who serve society by the application of sound medication management principles and strategies to improve health care for all. The Academy's more than 6,000 members develop and provide a diversified range of clinical, educational and business management services and strategies on behalf of the more than 200 million Americans covered by a managed care pharmacy benefit. For more information, visit

SOURCE Academy of Managed Care Pharmacy
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