Integrated Pharmacy Solutions Audit Defense
Audits conducted by Integrated Pharmacy Solutions can lead to substantial liability for pharmacies that are not prepared to defend themselves effectively. Our federal defense lawyers represent pharmacies nationwide during all types of Integrated Pharmacy Solutions audits. Call for a free consultation today.
Integrated Pharmacy Solutions (IPS) is an auditing company that works with managed care organizations (MCOs) around the country to assess the validity of pharmacies’ insurance billings. As a pharmacy that contracts with an MCO (either directly or through a pharmacy benefit manager (PBM), your billing practices are subject to review by the MCO and its third-party designees, and many MCOs hire companies such as Integrated Pharmacy Solutions to audit pharmacies’ billings on their behalf.
According to Integrated Pharmacy Solutions’ website:
“For over twenty-years, IPS 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 . . . .”
While facing an Integrated Pharmacy Solutions audit is very different from being audited by the Centers for Medicare and Medicaid Services (CMS) or the U.S. Drug Enforcement Administration (DEA), an IPS audit is still a matter that needs to be taken very seriously. Unfavorable audit results can lead to substantial liability, denial of pending and future claims, and loss of MCO and PBM contracts; and, in order to avoid these (and other) consequences, pharmacies need to assert a proactive defense during the audit process.
Our Pharmacy Compliance and Defense Lawyers Handle All Types of Integrated Pharmacy Solutions (IPS) Audits
At Oberheiden P.C., we represent pharmacies nationwide in Integrated Pharmacy Solutions audits. Integrated Pharmacy Solutions conducts several different types of remote and on-site audits, and it is important for pharmacies to rely on the advice of experienced counsel for all types of IPS audits. Our lawyers and pharmacy compliance consultants advise and represent pharmacies with respect to IPS audits including:
During an on-site audit, IPS auditors will visit your pharmacy in-person in order to review your pharmacy’s billing records and billing policies and procedures. While this can feel extremely invasive, MCOs and PBMs reserve the right to conduct such audits under the terms of their agreements with participating pharmacies, so there is little that pharmacies can do to prevent these audits from being executed.
However, during on-site audits, pharmacies can – and should – play an active role in the process. At Oberheiden P.C., we fulfill this function on behalf of our clients by engaging directly with IPS’s auditors, challenging their assumptions, and ensuring that they do not exceed their scope of authority. On-site audits can lead to a number of different consequences. We make sure these consequences are no greater than necessary for our clients.
Desk Audits and Mini-Desk Audits
Desk audits and mini-desk audits are conducted remotely, although Integrated Pharmacy Solutions conducts hybrid on-site/desk audits as well. When you learn that your pharmacy is facing a desk audit, mini-desk audit, or hybrid audit conducted by Integrated Pharmacy Solutions, it is important to engage pharmacy defense counsel right away.
Investigative Audits (Expanded Audits)
Investigative audits, which Integrated Pharmacy Solutions also calls expanded audits, are more-comprehensive versions of standard on-site audits. These audits often involve specific concerns about fraudulent billing practices—which may have been raised by an on-site audit, a desk audit, a patient complaint, or information supplied to your pharmacy’s MCO or PBM by a current or former employee. When IPS is conducting an investigative or expanded audit targeting your pharmacy, it is imperative to have highly-skilled defense counsel with specific experience in pharmacy compliance matters.
Integrated Pharmacy Solutions also conducts credentialing reviews to confirm that their clients’ participating pharmacies remain eligible to bill their payors. While this includes basics such as ensuring that pharmacies and pharmacists have current state licenses and DEA registrations, it can also include an examination of issues such as:
- Anti-Kickback Statute and Stark Law compliance
- Adequate fraud, waste, and abuse (FWA) training
- Compliance with Health Insurance Portability and Accountability Act and other pertinent data privacy laws
- Compliance with federal electronic prescription requirements
- Adequate quality assurance and diversion-prevention programs
340B Program Audits
As explained by the U.S. Health Resources & Services Administration (HRSA), “[t]he 340B Program enables covered entities to stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services. . . . To participate in the 340B Program, eligible organizations/covered entities must register and be enrolled with the 340B program and comply with all 340B Program requirements.”
Since eligible organizations are required to comply with all 340B Program requirements, this means that they also have an obligation to ensure that their participating pharmacies comply with the program’s requirements. To this end, in addition to conducting general pharmacy compliance and credentialing audits, Integrated Pharmacy Solutions conducts audits focused on ensuring 340B Program compliance as well.
If your pharmacy is facing a real-time audit by Integrated Pharmacy Solutions, you will need to be especially careful to ensure that your pharmacy’s billings are fully compliant. This means ensuring that your pharmacy’s billing policies and procedures are fully up-to-date and that they are being implemented effectively. Since we represent pharmacies with respect to both compliance and defense, we are able to assist with establishing and maintaining compliance in addition to handling any interactions with IPS on behalf of your pharmacy.
What Types of Issues Can Lead to Trouble During an Integrated Pharmacy Solutions Audit?
When conducting pharmacy audits, Integrated Pharmacy Solutions examines numerous different types of issues related to billing, credentialing, and legal compliance. For example, some of the most-common “red flags” for pharmacy auditors include:
- Billing Errors (Both Inadvertent and Intentional)
- Lack of Accurate and Up-to-Date Licensing and Registration Records
- Lack of Written Policies and Procedures or Documentation of Staff Training
- Filling of Prescriptions for Patients Who Pay in Cash
- Providing Patients with Frequent Refills
- Unorganized Record-Keeping
- Inventory Error Rates Above What is Considered Normal and Acceptable
- Dispensing Certain High-Risk/High-Suspicion Drugs (e.g., Oxy 30mg) or Known Dangerous Drug Combinations (e.g., the “Holy Trinity”)
- A History of “Failed” Audits or Investigations
- Referring Physicians Incentivized by Ownership or Other Financial Interests
For a more in-depth review of each of these issues, you can read: What are Red Flags for DEA Investigators During a Pharmacy Audit? While this article focuses on DEA audits and investigations, the red flags discussed in the article are all issues that Integrated Pharmacy Solutions auditors will be looking for as well.
How Can Oberheiden P.C.’s Pharmacy Lawyers and Compliance Consultants Help During an Integrated Pharmacy Solutions Audit?
Too often, pharmacy owners and pharmacists-in-charge assume that once an audit has been initiated, there is nothing they can do to affect the outcome. This is not the case. From identifying mistakes during the audit process to preventing auditors from exceeding the scope of their permissible authority, there are numerous steps that our experienced lawyers and consultants can take to protect your pharmacy during an Integrated Pharmacy Solutions audit. As your pharmacy’s audit counsel, we will:
- Communicate with IPS’s Auditors for You – Our lawyers and consultants (who include former senior DEA agents) will communicate with IPS’s auditors on your behalf. We will handle all requests for access, information, and records for you, and we will make sure the audit is no more invasive than absolutely necessary.
- Identify and Review All Pertinent Records – Once the scope of the audit has been determined, we will identify and review all pertinent records. The purpose of this is two-fold: (i) to understand what Integrated Pharmacy Solutions is going to find, and (ii) to ensure preservation of the attorney-client privilege.
- Conduct a Confidential Assessment Before IPS Reaches Its Own Conclusions – After reviewing all pertinent records, we will independently assess your pharmacy’s potential exposure in the audit. This will allow us to promptly identify flaws during the audit and address issues proactively before they lead to unjustified demands for retractions and other penalties.
- Assert All Available Defenses to Allegations of Non-Compliance – If IPS alleges that your pharmacy is non-compliant in any respect, our lawyers will use their extensive experience in pharmacy compliance matters to assert a strategic defense.
- Develop and Execute an Audit Response Plan – Finally, we will advise you regarding what you should do after Integrated Pharmacy Solutions’ audit is over. Does your pharmacy’s compliance program need any updates, additions, or modifications? Do you need to challenge IPS’s conclusions? Whatever the case may be, we can do what is necessary to protect your pharmacy against unnecessary liability.
Request a Free and Confidential Consultation with a Senior Pharmacy Lawyer or Compliance Consultant at Oberheiden P.C.
Is Integrated Pharmacy Solutions auditing your pharmacy? If so, our senior pharmacy lawyers and pharmacy compliance consultants can help. To schedule a free and confidential consultation as soon as possible, call 888-680-1745 or contact us online now.