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Academy of Managed Care Pharmacy (AMCP) Releases Model Audit Guidelines for Pharmacy Claims
Date:1/13/2012

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.

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SOURCE Academy of Managed Care Pharmacy
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