The Center for Medicare Services (CMS) employs Recovery Audit Contractors (RACs) and Medicare Drug Integrity Contractors (MEDICs) to conduct prescription drug audits of participating pharmacies. Audits can be conducted by RACs or program sponsors including United, Humana, CVS Caremark, Aetna, and Express Scripts.
Auditors look at a variety of aspects of a pharmacy to ensure compliance, but some key areas are:
- Document Review
- Submitted Claims
- Signature Logs
- Purchase Records
- Pharmacy Licenses
- Employees excluded from the Medicare program
For employees with excludable convictions, CMS audit contractors are typically looking for duplicate payments, prescription fraud, individuals excluded from Medicare, excessive controlled substances prescriptions and sales, and substitution of name-brand drugs with generic drugs billed under the name-brand code. In addition, the pharmacy audit will look for discrepancies in the number of claims vs. the number of medications for a particular NDC ordered.