With the considerable growth in the aging U.S. population comes a heightened need for pharmacies and their services. Medicare Part D drug expenditures rose 136% to $121.6 billion from 2006 to 2014 (OIG Data Brief, June 2015). Unsurprisingly, pharmacies’ dispensing and billing activities have come under increased scrutiny to expose and eliminate Part D waste, fraud, and abuse.


According to an HHS Office of Inspector General (OIG) report, “More than 1,400 pharmacies had questionable billing for Part D drugs in 2014.” A further area of OIG interest involves managed care organizations that have received payments that included outpatient drugs not covered on the Centers for Medicare & Medicaid Services (CMS) outpatient drug list.

The fiscal year 2017 OIG Work Plan included a focus on prescription drugs, including pricing and 340B rebates, and we expect future Work Plans to follow a similar course. So, now more than ever, pharmacies must establish rigorous internal controls to monitor prescription accuracy and completeness, and to be actively compliant with payer guidelines.

Are You Demonstrating Proper Pharmacy Compliance?

Community pharmacies have become the target of audit as evidenced by commercial payers turning to third parties for “invoice auditing.” Clerical errors, automated billing, and automated billing systems without problem detection are among the “lessons learned” from such audits. The penalty for non-compliant pharmacies is steep, including an underlying threat of network expulsion.

With more than 30 years’ experience advising clients in all 50 states, PYA offers ongoing assistance for pharmacies striving for compliance with federal regulatory guidelines.

PYA can assist pharmacies with the following compliance needs:

  • Day’s supply limits/calculations
  • Pharmacy benefit management (PBM) audits
  • Independent Review Organization
  • “Dispense as written” (DAW) assistance
  • Prescription documentation
  • Appeal assistance
  • CMS policy interpretation
  • Post-audit defense support
  • Ongoing support for proper claim submission
  • Data analysis services
  • Education and Training


PYA has extensive experience in providing superior services to pharmacy providers including:

  • Community/local pharmacies
  • Hospital pharmacies
  • Specialty pharmacies
  • Home infusion pharmacies
  • Drug manufacturers and specialty drug distributors
  • Third-party administrators
  • Medicare Part D plans

PYA’s cross-functional, hands-on experts are well-versed in the complex healthcare regulatory environment and are poised to assess your pharmacy procedures for potential compliance concerns. Our independent compliance team understands how rapidly the industry changes, and is prepared to help you address challenges along the way. If you have questions regarding pharmacy compliance or how PYA can assist, contact one of our compliance team experts.