“Watch out…here comes the term-auditor”

Being a pharmacy intern at Blue Cross has many great perks. Not only do I get to learn the meat and potato of my own team (Pharmacy Networking/Contracting), everyone always seems to be presenting me their best offers.

“Best offers” right now would surely have to be the different experiences that I’m seeing and learning everyday in the Managed Care world. And for the first time, I got to go on an auditing trip—a side of pharmacy business that I never thought I would be part of.

The way Blue Cross carries out its auditing process is different than most other insurance companies. While most insurance companies focus mainly on the expensive drugs (such as specialty drugs; ie cancer drugs) during their auditing process, Blue Cross is out to ensure that ALL drugs are billed the correct way.

Before going out to the “chosen pharmacy,” the auditor would randomly select a set number of prescriptions that have been billed to Blue Cross within the last year. Upon arriving at the pharmacy, the auditor would request few more random prescriptions to be pulled. This way, the process consists of both prepared and surprising elements that will ensure the fairness of the auditing process.

From there, the auditor will go through the hundreds of prescriptions that have been pulled, and compared them with the billing records one by one. If ANYTHING is different from the billing records—patient name, medication, quantity, missing signatures, etc, the pharmacy is subjected to a fine OR an educational lesson (aka a simple warning). If certain violations are found, the financial penalty will be EXTRAPOLATED for the entire year worth of claims filed. Such extrapolation process can be good and bad—depending how you look at it.

The actual pharmacy visit was more civil than I had imagined. We were handed the requested scripts right off the bat and were left alone to work on them for the rest of the day. Perhaps most people figured that a happy auditor can only means a happy turnout, so they all left us be. I invite whoever has been through a pharmacy auditing process to comment on this entry and let me know what it was like to be on the pharmacy side.

Overall, the trip was an experience that I will hold dearly to my heart as I progress through my career. Whichever side I end up being working for, it’s always good to know the proper rules so there’s nothing to worry about. In addition, this experience continues to amaze me just how many opportunities are out there for pharmacists.