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Pharmacy Auditing Services

imageWhat separates IPS and its Team from other audit vendors? Our assurance to you is that our customized audit program will:

  • Focus on quality measures
  • Be free from any financially driven incentives
  • Emphasize educational opportunities for network providers
  • Provide meaningful feedback to benefit and program integrity coordinators

Pharmacy Claims Integrity
A recognized industry leader in pharmacy auditing services, Integrated Pharmacy Solutions, Inc. (IPS) understands that today’s complex environment of healthcare reform and escalating health care costs requires managed care organizations (MCO) to continuously analyze claims data and reposition operating standards.

For over twenty-years, IPS has partnered with MCO’s to meet these unique service demands and has provided clients with reliable non-incentive performance based pharmacy claims audit results. The IPS audit program is designed to strategically convey quality driven transparent pharmacy auditing services to providers with assurances to ensure for optimal network integrity and quality performance.

IPS utilizes concise pharmacy auditing standards and contemporary audit tools to fundamentally assess, monitor and control pharmacy service health care costs and improve operational effectiveness. The internally constructed audit platform used by IPS leverages sophisticated analytics to assess proprietary-criteria and benchmarks to conduct in-depth audits for clients to ensure detailed, timely and accurate results.

The pharmacy audit programs have been engineered to optimize client satisfaction, improve administrator accountability and facilitate provider educational awareness regarding quality improvement measures and industry recognized best practice standards.

Resultant audits are conducted by qualified personnel regarded for specialty audit knowledge and insight with particular focus on assessment of quality assurance indicators including integration of industry acknowledged best practices to improve operational outcome performance.

IPS client’s resoundingly affirm and value the company’s steadfast commitment to continuous quality improvement, customizable audit design, technical information management excellence and customer satisfaction as evidenced by longstanding contractual relationships.

A multi-disciplinary approach is employed by IPS for both the audit and credentialing programs. This methodology is structured to assist the MCO’s to strengthen claims processing, improve pharmacy and prescriber adherence and provide for an analysis of network compliance with regard to federal and state statutes and regulations including but not limited to OBRA, OIG/GSA, Medicare Part D and HIPAA compliance requirements.

Comprehensive audits are routinely conducted by the IPS audit department to validate pharmacy data entry and documentation to ensure the same meets regulatory and contractual requirements and where applicable identifies, documents and eliminates fraud, waste and abuse (FW&A).

The IPS audit service program integrates several strategic strategies thoughtfully arranged to generate the most effective and efficient pharmacy claims integrity analysis available.

In a quality obsessed and cost-efficient manner, IPS can customize and implement affordable state of the art pharmacy network audit programs each tailored to provide clients with meaningful solutions to meet specific organizational needs. These developed strategies include:

  • Direct patient and prescriber mailings
  • On-Site “live” audits
  • Desk audits
  • Mini-Desk audits
  • On-Site/Desk audits
  • Investigative or expanded audits
  • Credentialing review
  • Real-time audits
  • 340B Audits
  • Appeals Management
  • Network Recommendations
  • Auditing Software Lease and Support

IPS’s highly trained and experienced management team operates sophisticated technologies to uniquely analyze pharmacy claims data. At the core of our auditing program is our pharmacy stratification system. This stratification is reconciled against one-hundred percent (100%) of the claims data provided and produces a network scorecard for each pharmacy. The data assessment stratification metrics may be fluidly customized to specifically evaluate any particular variances identified by clients.

imageThe stratification process utilizes dozens of refined analyses and scoring formulas to determine the most appropriate candidates to audit for fraud, waste and abuse and potentially inappropriate billing. Analysis of IPS stratification data is a fundamental step in formulating recommendations to clients concerning an effective and efficient audit selection assortment.

After preliminary audit combinations are formulated, further collaboration with clients and subsequent software re-applications are processed to determine the most appropriate claims to audit.

Thereafter, qualified and skilled IPS audit professionals conduct timely and efficient pharmacy audits. The resultant audit results may identify value-added reports related to potential over-payment recovery, recommendations for implementation of risk-management best practice standards, opportunities to improve performance and compliance with existing clinical intervention programs, educational outreach ventures for providers and improved operational compliance to network program parameters depending upon client directives.

IPS auditing and data management personnel uniquely review and navigate all areas of prescription drug benefits, provider performance as well as contract and regulatory compliance. IPS has been qualified as a CMS Medicare auditor and has participated in an advisory group to detail the CMS audit recommendations.

IPS pharmacy claims auditors are experienced pharmacists and certified pharmacy technicians that are fully trained and skilled in identifying inappropriate, potentially fraudulent and deficient billing practices. Many data management and audit projects have been customized to meet client’s requests and dually serve an educational capacity to demonstrate that inherent audit program services can be custom-made to effectuate behavior modification and quality assurance rather than solely financial sanctions. Examples of similar data management projects include:

  • Network Pharmacy claims audit experience ranging from retail, long-term care, 340B and Medicare Part D pharmacy audits across the 48 contiguous states
  • Pharmacy Benefit Management (PBM) audits
  • Rebate Auditing
  • Fraud, Waste, and Abuse Programs and Investigations
  • Drug utilization analysis and programs designed based on the results
  • Drug disease management initiatives
  • Data protection processes
  • Improvement of operational effectiveness
  • Compounding based audits
  • Regulatory Compliance Assessments

SAMPLE PROJECTS

  • A self-insured health plan contracted with IPS to conduct and audit on the pharmacy claims process by their PBM. The audit reviewed up to date pricing, accurate dispensing fees, application of co-payment, compound prescription pricing, and other criteria. IPS evaluated the claims and reported all discrepancies as well as made recommendations for reclaim.
  • A pharmacy data management firm contacted IPS to conduct an audit on manufactures rebates on behalf of a client. IPS identified inconsistencies in rebate payment practices in our audit findings and provided recommendations for reclaim.
  • After a reported controlled substance loss, a hospital contacted IPS to perform routine site inspections, audits and review of all aspects of pharmacy services related to controlled substance management, delivery, administration, record keeping and disposition.image
  • A nursing home contacted IPS after the Department of Public Health directed them to engage in an outside independent pharmacy service. IPS performed a full review of all patient profiles and medication orders to ensure accuracy, prepared a report of the findings and provided recommendations for correction.

IPS’s new web portal also allows clients to contemporaneously login (secure) to determine the status of an audit or audit series, create and download audit summary reporting tools and request additional pertinent information.

Please contact IPS today by telephone 781-333-6040, e-mail info@integratedrx.net or visit our website at www.integratedrx.net to learn about additional opportunities to utilize these innovative products to develop effective, efficient, customized audit solution for your respective managed care organization. We look forward to hearing from you in order to capably assist you to achieve and sustain superior audit performance results.

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