For years, one of the biggest fears for pharmacy owners in this regulatory world is the OptumRx audit. Having shown up on the scene in 2010, at the time known as Catamaran audits, now known as OptumRx audits are impacting community pharmacies in a BIG way. To further keep you stress-free and in compliance, here’s a breakdown of what you and your pharmacy staff need to know to prepare for a OptumRx audit and avoid penalties.
OptumRx audits are a Medicare Part D auditor. The best way to explain a OptumRx audit is as a combination of a CMS onsite, state board inspection, and medicare accreditation survey all wrapped into one.
You’ll receive a postcard notice roughly two weeks before your scheduled audit with a specific date and time, generally 9am or 1pm, for when your auditors will visit your pharmacy.
This list below will give you a good idea of the items you need to have in order right away and to avoid the severe penalties.
• 2 years - State Pharmacy Board
• 6 years - HIPAA Compliance
• 7 years - Medicare Part B
• 10 years - Medicare Part D
Your records don't have to be located onsite. You can have them in another offsite and secured storage location or you can scan the records after two years and store them electronically as long as you have a good backup system.
A big change for most pharmacies in the country is that they have never had specific policies and procedures for their day-to-day operations. OptumRx is constantly adding additional procedure requirements to their audit checklist that many pharmacies will need to add these specific policies and procedures.
If discrepancies are found during your OptumRx audit, you may find your pharmacy facing a simple warning to 100% of your reimbursements being pulled. The most severe penalties are for not conducting your Fraud, Waste and Abuse, HIPAA training and OIG exclusion verification. If you cannot prove that you are running the OIG exclusion every month, OptumRx will report it back and the third party can pull 100% of the Part D reimbursements that you received for the period of time you were not doing the OIG exclusion. The worst part of this situation is that there is no appeal. Most pharmacies could not withstand that loss and stay in business.
At R.J. Hedges & Associates, we have created a thorough checklist to prepare you for the OptumRx audit. Your R.J. Hedges Project Manager will guide you through this process. It’s ready for our clients to use immediately and included in our Fraud, Waste and Abuse Program. If you are not a current R.J. Hedges client and are not confident your pharmacy can pass a OptumRx audit, I invite you to speak to my team to find a solution you are looking for.
Preparing for a OptumRx audit is very important as the repercussions can be so drastic. Right now it’s just a matter of time... when will the OptumRx auditor walk into your pharmacy? Several of our clients have already been audited, and while one did receive a warning for not documenting the CMS-10147 form, none had any penalties. We’ll continue to keep you informed so you can pass the OptumRx audit seamlessly as well.