A new auditing trend has emerged among some PBMs (including CVS Caremark) focusing on the “exclusion” status of prescribers that have written prescriptions filled by the pharmacy. In recent audits, CVS Caremark has examined pharmacies’ dispensing histories and scrutinized claims dispensed by the pharmacy that had been written by a prescriber that seemed to appear on the OIG’s Excluded Provider List.
The OIG’s Excluded Provider List – or List of Excluded Individuals/Entities (LEIE) – contains all individuals and entities that are currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs, and is intended to provide information to the health care industry, patients and the public regarding these excluded individuals and entities. If a provider appears on the Excluded Provider list, they may not submit claims to any Federal health care program, may not be employed by an entity that submits claims to a Federal health care program, and may not refer or prescribe for services (such as prescriptions) that are ultimately submitted to a Federal health care program. Many private insurance contracts extend these rules to commercial claims as well.
Providers can be placed on the Excluded Provider List for a variety of reasons, including conviction of a crime, settlement of a False Claims Act case, or even certain professional discipline (such as suspension of a license to practice).
Historically, OIG or payor audits have focused on entities that employ excluded providers. However, in its recent audit, CVS Caremark expanded this inquiry, and culled out certain claims filled by the pharmacy that the PBM believed were written by an excluded provider.
With this new type of auditing, providers are not only obligated to ensure that they do not hire any excluded providers, but now pharmacies are being scrutinized for accepting prescriptions written by excluded providers. This means that pharmacies essentially have to check every physician from whom they receive a prescription before filling it. This can create real logistical problems for pharmacies, as excluded providers are not always listed in the Federal database by NPI number, making it very difficult to block prescriptions from excluded providers using many pharmacy software programs. In addition, providers may from time-to-time appear on the Federal Excluded Provider List, but not appear on the corresponding State Medicaid exclusion list (or vice versa). This too creates difficulties for pharmacies in ensuring they do not dispense prescriptions written by excluded providers.
In sum, pharmacies must ensure that they take steps to not only avoid hiring of excluded providers, but also to avoid submitting claims for prescriptions written by excluded providers. If your pharmacy is facing audit over prescriptions written by allegedly excluded providers, or is looking to bolster its practices, contact Frier Levitt today.
