Female Pharmacist

PHARMACY AUDITING SERVICES

You’ll find plenty of services at Integrated Pharmacy Solutions, and we’re always adding more. We do more than just fill your prescriptions—we are your partners in health and even a valuable source of information. Our Pharmacy provides a wide range of services to keep patients on the road to well-being.

 

WHAT SEPARATES IPS AND ITS TEAM FROM OTHER AUDIT VENDORS? OUR ASSURANCE TO YOU IS THAT OUR CUSTOMIZED AUDIT PROGRAM WILL:

·     Focus on improvement of network quality and measures 
·     Non-risk-based contracts
·     Emphasis on educational and quality improvement opportunities for network providers
·     Provide meaningful feedback to benefit and program integrity coordinators

PHARMACY CLAIMS INTEGRITY

As 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 require managed care, Medicaid, and Medicare organizations to continuously analyze claims data to monitor contract compliance.

For over twenty years, IPS has partnered with PBMs and health plans to meet these unique service demands and has provided clients with reliable, pharmacy claims audit results and network compliance. 

IPS utilizes concise pharmacy auditing standards and contemporary audit tools to assess, monitor, and identify potentially inappropriate claims. 


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.

Our pharmacy audit program has been designed to optimize client satisfaction, improve administrator accountability, and facilitate provider educational awareness regarding quality improvement measures and industry recognized best practice standards.

IPS clients value the company’s steadfast commitment to continuous quality improvement, customizable audit and report design, and customer satisfaction as evidenced by longstanding contractual relationships.


Our approach is structured to assist the MCOs 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 Medicaid, 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 minimize fraud, waste and abuse (FW&A).

IN A QUALITY-FOCUSED 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:

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

IPS’ HIGHLY TRAINED AND EXPERIENCED MANAGEMENT TEAM OPERATES SOPHISTICATED TECHNOLOGIES TO 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 variances identified by clients.

The 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 plan.
After preliminary audit plan is 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 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 POTENTIALLY FRAUDULENT AND INAPPROPRIATE 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, veterans, Medicaid, and Medicare Part D pharmacy audits across the 48 contiguous states

  • Pharmacy Benefit Management (PBM) audits

  • Rebate Auditing

  • Fraud, Waste, and Abuse Investigations

  • Clinical drug utilization analysis and programs designed based on the results

  • 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.

  • 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.