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AMCP Offers Model Audit Guidelines for Pharmacy Claims

The 21-page Model Guidelines document was developed by a diverse group of pharmacy stakeholders. It is designed to help managed care organizations (MCOs) develop an effective pharmacy claims audit program, while helping pharmacists to better understand audit requirements and processes.

The Guidelines include the following sections:

  • The Role of Audits
  • Fraud, Waste, and Abuse
  • Data Entry and Documentation
  • Philosophy and Responsibilities
  • The Audit Process
  • Description of Audit Types
  • Audit Process: Outline of Procedures
  • Concurrent Daily Review Audits
  • Desktop Audits
  • In-Pharmacy Audits
  • The Appeal Process
  • Compounded Medications—General Discussions and Guidelines
  • Long-Term Care—General Discussions and Guidelines
  • Privacy Concerns
  • State and Federal Oversight
  • Pharmacy Audit Transaction Standard
  • Glossary

The Guidelines stem from AMCP’s establishment of the Community Pharmacy Outreach Advisory Council in 2009. The Council is designed to address common issues between managed care pharmacy and community pharmacy as a means to enhance the relationship between the practices. The Guidelines were developed over a year by a taskforce composed of pharmacists and others from MCOs, community practice, law, auditing administration, third-party management, and network administration.

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