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The Bottom Line Pharmacy Podcast: Sykes & Company, P.A.
Pharmacy Audit Masterclass: Strategies for Audit Success Featuring Trenton Thiede, President of PAAS National
Navigate pharmacy audits in this masterclass!
In this episode of The Bottom Line Pharmacy Podcast, Scotty Sykes, CPA, CFP and Bonnie Bond, CPA sit down with Trenton Thiede, President of PAAS National to discuss all things Pharmacy Audits including:
- Best practices for copay collection
- Current trends and tactics in PBM audits
- Proactive strategies that reduce audit risks
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Want to read and follow along with this episode? Click here for the transcript:
More about our guest:
Trenton Thiede is the President of PAAS National (Pharmacy Audit Assistance Service).
Trenton started his journey working at Shopko, a community pharmacy, in 1999 for15 years, holding positions as Pharmacy Manager and Regional Pharmacy Supervisor while completing his PharmD from UW-Madison and MBA from UW-Oshkosh.
In 2013, Trenton took over Shopko’s Long-Term Care division and helped divest it to KPH HealthCare (Kinney Drugs/HealthDirect). There, he helped grow their business throughout the Midwest, eventually servicing 20,000 beds in just under four years.
In 2018, Trenton joined PAAS and oversees the daily operations as President. With his operations experience, Trent knows what’s involved, and at stake, with pharmacy audits; taking pride in helping independent pharmacies win against ruthless PBMs.
Learn more about Trenton and PAAS National:
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Scotty Sykes, CPA, CFP®: Well, welcome everybody to another episode of The Bottom Line Pharmacy Podcast today. We have Trenton Thiede Did I get that right?
Trenton Thiede: You got it. Yep.
Scotty Sykes, CPA, CFP®: With PAAS national. I kind of like that. It kind of rolls off the tongue nice Thiede with PAAS and I'm sure everybody here is familiar with PAAS if you've been to any trade show If you were at any trade show this summer and you visited our booth, you would have seen next to us because we had them at beside us at McKesson and who What was the other one? Drawing a...
Trenton Thiede: ThoughtSpot, Amerisource.
Scotty Sykes, CPA, CFP®: ThoughtSpot. That's right. So, Trenton, welcome to the show. Glad to have you. Tell us a little bit about, you know, yourself, what you guys do there. And then kind of just roll roll from there.
Trenton Thiede: Yeah, sounds great. Well, it's great to be here. Thanks so much for having me. I'm Trent, president of PAAS. I'm a pharmacist by trade. I spent 15 years working for a small community retailer up in Wisconsin, where I'm from. Originally out of Green Bay, of course, so a big Packers fan. So worked for community pharmacy about 15 years and then spent the last four or five in long -term care before coming to PAAS. So, I ran long -term care pharmacies in the Midwest. But then came to PAAS, I've really come to love what we do in helping community pharmacies, especially independents, combat PBMs and PBM audits. So, for those that maybe aren't familiar with PAAS, it stands, the acronym stands for Pharmacy Audit Assistance Service. We've been in business for 30 years helping community pharmacies in their dealings with PBMs. Primarily when it comes to audits, we do a few other things as well, but most of us, most people know us for our audit assistance. We're pharmacist -owned and managed. We have five pharmacists on staff, seven certified technicians, and a host of other ancillary staff to help support our pharmacies. Last year, we saw 10 ,000 audits.
Scotty Sykes, CPA, CFP®: Gosh, that's crazy, that's a lot.
Trenton Thiede: So, we're using all that intel and guidance from the audits that we see to help provide insight and feedback back to our members. I think audits, and I'm sure we'll talk about it, but we're very much of the belief. A lot of people think when they think of audit assistance is when they get an audit, right? I need audit assistance now, now that I have an audit in hand. And really we very much focus a big part of our service on being proactive. And I'd to talk to you guys about the things we do, what kind of trends and tactics we're seeing, what things pharmacy owners should be aware of to help mitigate their audit risk.
Bonnie Bond, CPA: I know that's a common phone call I get or an email. Nothing that we can really do about it, but you know, the pharmacy client's like, no, I've got an audit and they are panicked. So, it's not fun. So, I am so interested to hear about the proactive part of it because that really isn't on my radar either. So, talk to us about that. So, things you can do with you guys before you get the notice that this is going on.
Trenton Thiede: Yeah, and PBM audit notices are daunting, right? They can be very intense. These are the big behemoths that you're already afraid of. And so, them coming in to audit is a very scary feature for lot of owners who haven't been through them. Or if they're coming on site, it can be very intense. So, one of the things that we focus our services on is being proactive. And so how do you be proactive? Audits are always retrospective, right? The claims you're billing today are the audits of a year, two years from now. If you're lucky, we can see audits, particularly with Medicaid, go back five years. So, it's about the claims that you're billing today. So how can you be smarter about the claims that you're billing today? And part of that comes from insight and knowledge about what are the PBMs doing? What things should I do or not do? So, at PAAS, we write internally, we write a monthly newsletter. It's 12 articles. We physically mail that to all of our members, telling them, here's what the PBMs are auditing. Here's what to do. Here's what not to do. So, a big part of that is just making them aware of these audit trends and tactics and talking to them about general filling and billing guidance. So we can dive into some of each of those examples. But if a pharmacy doesn't know how to bill a claim correctly or they have questions or they're not sure, that's part of our services. Once you're a member, there isn't any additional charges or fees. It's an annual membership fee. We're a membership -driven organization. And so however we can help, we're very much a servant leader. How can we help you be successful when it comes to audits? Filling and billing claims correctly, and then being reactive, obviously, when they have an audit, taking them through that process. But we focus a lot of our time and attention on helping pharmacies avoid those in the first place. And we have statistics that can show the longer a pharmacy is with us, the less likely they are to be audited and the better off they are in terms of recoupments.
Scotty Sykes, CPA, CFP®: So, the less likely they are to be audited and well, that's interesting. So these audits aren't kind of random?
Trenton Thiede: They're rarely ever random, right? They're very targeted, high dollar claims, looking at it's all your insulins and biologics and they are not random. There are a few states that have some state laws. We very much push for premium reform, not only at the federal level where we support it with through NCPA, but also at the state level, right? There's a ton of reform. Everyone's familiar with that. And there are some states, I love Arkansas, obviously, not only from the Rutledge PCMA spearheading that they had. But also they have some great laws about randomization for audits and limits on the number of claims to be audited. It doesn't always translate to Medicare and Medicaid being federally funded, but for commercial claims and things like that, they're random. But most audits, to your point, Scotty, they're not random. They're very targeted. They're going for high dollar claims, looking to recoup what they can.
Scotty Sykes, CPA, CFP®: And once they audit you a couple of times and you Pass those audits with flying colors per se, they kind of just pass over you. No pun intended. Next. Right. Might have to steal that one.
Trenton Thiede: Yeah, we always tell pharmacies to challenge, right? Never make it easy. Don't make a recoupment easy because then they'll come back, right, where it's easy to get it. So always fighting. But also, they're using data analytics, right? They're using AI to comb over your claims data to say, here's a high likelihood that I can recoup from Scotty's pharmacy. And so, if there's no anomalies, if your claim billing history looks really good, you're also less likely to say, I'm going to go visit there. Well, they're going to go where they can find easy claims, where they know it's been rebilled multiple times. They know these factors and are looking to play you for it.
Bonnie Bond, CPA: We have a lot in common Trent, that's very similar to the IRS I believe. They have AI and dig down, they know where to find that stuff. Different sectors of different type of things, schedule C's, that's why we push our pharmacies never to be a schedule C, because they're gonna come dig it in places like that. And we definitely are with you on the proactive side, accounting, yeah, it's huge.
Scotty Sykes, CPA, CFP®: Nobody likes audits, IRS audits, PBM audits, boy, they're just not fun.
Bonnie Bond, CPA: Sales tax audits...
Scotty Sykes, CPA, CFP®: Sales tax audits, just not fun. So, Trenton, somebody comes on board with PAAS. Do y'all do like an initial review, kind of get in there and see where they are, what they've done, kind of a checklist kind of to get you up to speed type thing, or how does that work? I'm just curious.
Trenton Thiede: Yeah, it's great question. So, about half of our members, when they join, about half of them join when they're in an audit and half of them are joining just for that proactive piece. They're familiar with it. So, it depends on circumstances, right? If they're in an audit, we're just diving in. What do you got going on and where are you at with this audit? Sometimes people will join us pre-audit. Like they've just got the audit notice, and they've signed up. And sometimes they've tried to go through the audit. It hasn't gone well. And now they've got results that are significant and they're looking for assistance. And we jump in at all stages. From the proactive standpoint, we send out a member manual and we send out a lot of our tools and aids. One of the big things that we have are day supply charts. We often give some of them away at the trade shows. But again, it comes to helping pharmacies fill and bill claims accurately. So, we have a ton of proactive resources on how to handle different scenarios in the pharmacy correctly, how to manage claim rejects, how to make sure that the right flags are checked when you're billing these claims. And we have these nice charts that help train staff and new technicians or experienced technicians how to make sure they're doing everything correctly to, again, lessen that likelihood of an audit. And also, it's less for the pharmacist to catch, right? The more the technicians can accurately fill and bill claims upfront, the less the pharmacist has to worry and check everything and the more they can focus on making sure that the prescription is dispensed accurately.
Scotty Sykes, CPA, CFP®: Interesting so what the what the proactive piece in place, know, what are some trends? Trent that you're seeing out in the marketplace right now. I know we've had Brown and Fortunato on the podcast month or two ago talking about Talking about trends in the audit space as well. What are you guys seeing there?
Trenton Thiede: Yeah, we definitely see an increase. I'll tell you in fraud, waste and abuse. I think is what Brad, Brad talked a little bit about. I watched that podcast, and S I U or special investigation unit, they're kind of similar FWA or SIU depends on the PBM. But similar in scope, right? They're getting more aggressive in terms of going after pharmacies. They also try and skirt state audit laws because a lot of the state audit laws carve out exceptions for fraud, waste or abuse. So, more audits are being identified that way. So, they don't have to follow potentially state regulations. They don't typically have an obligation to show anyone that they had a credible suspicion of FWA. So, if they just put FWA on the audit notice, now they're working around some of the systems. I think one of the big things that we see right now is invoice audits and helping pharmacies navigate invoice audits. Invoice audits are by and far probably the audits that result in the most six or seven figure potential recoupments for pharmacies. Just huge. They can devastate a pharmacy. Caremark, I mean, the big three are dominating audits as a whole, as you would expect. But invoice audits for sure are a big problem. Optum is very aggressive. And it's invoice audits to kind of break it down a little bit. Over a specified period of time, they're looking at what did the pharmacy buy and what did the pharmacy bill for? And they're trying to match up those claims. And each PBM kind of has their own nuances to that and how they treat that invoice audit. But I'll give you an example with Optum, who I think is the most difficult. Pharmacies have to produce redacted claim data for that specified timeframe. So Optum, you have to take your pharmacy management system, or they'll go straight to the pharmacy management system, produce your dispensing record over, let's say, 12 months. And then they're going to have you contact your wholesaler, whoever that might be, and submit the purchasing records. And they want it straight from the wholesaler. They don't trust independent pharmacies. They won't let the pharmacies touch the files. And so, the wholesaler has to send over the file to the PBM. And the PBM does a reconciliation. And they're saying, you billed for 10 Lantus Solostar pens, and during this period of time, you only bought nine. So, you owe us one back. That's where we see lots of problems with reconciliation. There's many issues with invoice audits and independent pharmacy owners rightfully get frustrated. Part of it is they don't count inventory on the shelf. I know you guys, and being good stewards of cash management, right? You want to have low, lean inventory in pharmacies. So, they're not carrying a lot, but pharmacies that do or potentially purchased another pharmacy or were strategically buying, all those situations can create issues in an invoice audit if you're buying in bulk or other situations that aren't easily accounted for. It creates huge issues and massive discrepancies when it comes to invoice audits. And I think that's where a lot of pharmacies struggle with that.
Bonnie Bond, CPA: Well, just looking at your website, one of the things that I noticed that stuck out to me was that you guys, your data shows that you've got what, 89%, 90 % reduction in audit findings. So that's huge. Yeah.
Trenton Thiede: Yeah, it's a five year average for us. And it's when we get involved at the start, right? It's very much helping pharmacies. We review documentation before submission to a PBM. So, we're looking at your scripts, looking at what you've got. And there are some components with invoice audits that can help out to make sure that you don't have discrepancies. A big part of purchasing as well, and this goes to the proactive piece, is where you're buying from. Sometimes owners get caught up in just finding the lowest cost for a product. And sometimes it's not always the best choice, right? There may be, if it's too good to be true, it probably is that saying goes, test strips are a great example. A lot of pharmacies still get burned on diabetic test strips, diabetic testing supplies, because they're not procuring them from the right source. As an example, there was a lot of fraud with diabetic testing supplies years ago in 2015, 2016, and some of the diabetic test strip manufacturers ended up suing the PBMs, suing pharmacies because they were paying more in rebates than they were selling in product. So, then there was a problem. They were importing it from overseas. was gray market product, selling it again, repurchasing from patients, things like that. So, they put into the contracts with some of the big PBMs, you can only buy from our authorized distributor list. And so, Roche, LifeScan, these entities produce a list of their approved suppliers, distributors, and they say they're forbidden from reselling. So only these entities will have legitimate product, anyone else, and they're going to argue it's not legitimate product. They can't have it because we don't allow it to resell. And so CareMark, ExpressScripts, two great examples, explicitly require pharmacies to buy from that list. And the challenge is there are other OTC distributors out there that aren't on the list, but will still gladly sell test strips to pharmacies. And they may or may not say, hey, we're not an authorized distributor of record for this diabetic supplier, but pharmacies get caught up in that. And so now I'm not buying test strips from the right place. I get an invoice audit. I have purchases, but they don't count. And so that really can add up very quickly for a pharmacy that's doing a lot of that diabetic testing supplies. We see it all the time and it's just a huge miss and that's being proactive, right? Knowing that because there's nothing you can do about what you bought yesterday. All I can do is buy correctly going forward and it's that kind of educational components we try and provide to mourn pharmacies because when sometimes when you're in those, we can't fix it. All we can do is try and mitigate standards from there.
Scotty Sykes, CPA, CFP®: These invoice audits, man, I'll tell you, they sound like gotchas to me. I mean, you gotta think 99 % of the pharmacies out there have bought what they said they bought. They filled it. Maybe 1 % or whatever. One out of a hundred is doing something they shouldn't be doing, but let's get real here. I mean, pharmacies are buying the drugs, they're filling the drugs. And so, these invoice audits just seem like gotchas to me. And this is just another reason why PBMs are just...
Trenton Thiede: No, absolutely is right. 99 .9 % are doing the right thing, the right ways, buying the drugs. And it's the 0 .1 % that the PBM uses as fuel for the fire, right? Hey, look at these, look at this fraud where there is maybe a situation of crime. And then they get somebody caught up in, I didn't have the right invoice or I didn't have my paperwork for that, but I did buy it. You know, it's unfortunate.
Bonnie Bond, CPA: So, you really have two ways for people to get going with you guys, Trent. It could be, I've got my audit in hand. Kind of the not so proactive approach and then a proactive approach of just going ahead ahead of time and contacting you. What does that look like to get started?
Trenton Thiede: Yeah. So, I mean, we use NCPDP data feeds. So, we have all the pharmacies and the information. It's super simple because pharmacies can just go to our website and sign up, or they can give us a call. We have a call center that answers our phones. We promise on any contact, like a two business day turnaround. So, we're very quick to respond to a pharmacy. If they have a deadline today, if they joined today and send my audits due today, we would help them. It's just what can we do with the time that we have given your circumstances, given what you need. So, we're very quick to turn things around. When we can, we have a great team that's very experienced and knows kind of how to navigate those processes. So, when they get started, we can really jump in predicated on circumstance. And if they have quick questions, like sometimes members will just join and I want to know what's hot right now or what things should I be aware of. And I'll give you a couple of examples because I'm curious on one of them for sure to get your take from the accountant perspective, right? I'm sure you guys potentially hear this or see this, but proof of copay collection. Right? So, we're seeing more audits, particularly from Caremark of the big three, proof of copay collection. And so, one of the main things we tell pharmacies all the time is you have to get with the times. If you don't have an integrated point of sale system, you're going to run into problems with PBMs. Like you have to, we're agnostic with pharmacy management systems. It doesn't matter what integrated point of sale system, you got to have something that can show evidence of copay collection, hopefully it integrates so that you have a bunch of additional features...
Trenton Thiede: There’s still pharmacies out there without a PMS?
Scotty Sykes, CPA, CFP®: Not without a POS. Yeah. Yeah, there are. And those guys get, torched, unfortunately, you know, it's, it's somebody, you know, it's got, got, we got people that are potentially in their seventies and they've run it all that way all along and been very successful. And, and my heart bleeds for them. Cause it's like, guys, I get it. You gotta get with the times on this stuff. And one of the challenges that a lot of owners face is cash payments. And this is why I think I'd be interested in your take, right? Because we tell pharmacies, cash management, when you're claiming a cash copay, you've got to have record. And what Caremark looks for is bank deposits. And what we tell pharmacies routinely is you should have a routine process to deposit cash into the bank, whether that's weekly. I think weekly is appropriate or monthly, so that you have record of it. And you also can't dip into the till to pay another vendor, to pay someone else, you can't use it as petty cash, right? And I would imagine that plays right into your area. And don't know if you run into a lot of problems with that cash management, but we tell pharmacies all the time, especially when they're taking a 200, a 300. I see pharmacies with $800 copay and they took it in as cash. I'm not saying you can't take cash. Where's your record, encouraging and making sure you have clear documentation, just like an IRS audit to your point. What can you show the PBM at that point to make sure that you can demonstrate that you collected that copay?
Scotty Sykes, CPA, CFP®: And I'll answer that question, Trent. What we suggest pharmacies do is that they take the end of day point of sale report. They're getting that in the accounting system and then they're tying the bank deposit every single day. Ideally cash deposit, making your deposits daily, ideally. And, you're tying that into the point of sale register each day. So everything reconciles every day.
Trenton Thiede: Yeah. Love that.
Scotty Sykes, CPA, CFP®: And then, you know, when the audit comes IRS, PBM you got it buttoned up. And if an auditor runs into that and they see that you have this process in place, that you're reconciling daily, so on and so forth. I mean, they're gonna, they're just probably gonna move on to the next thing. mean.
Trenton Thiede: I love that. Absolutely. Where they can't get money, I totally agree. And I think that's great process. I'm glad to hear that. Daily, think, is certainly ideal because then there's no question. If you took an $800 cash for the day, you have proof, have evidence. And it's real simple to show that. What I run into, as you can imagine, is they're not depositing the cash or they only deposit on a rare or infrequent, not routine basis. And they're not able to reconcile. And it's just a mess. And the auditors love that kind of stuff because then they can just keep digging deeper and ask for more. Sometimes in these FWA or SIU investigations, they start to find things and it's not over. So, then they ask for more scripts. you're not able to meet these? Show me some more. Show me some more. And those get to be really arduous really quickly for owners. So having clear policies like that really can help.
Scotty Sykes, CPA, CFP®: Sure does.
Trenton Thiede: You know, part D regulation, right, is 10 years plus the current plan year. And that's an extreme example, those are typically true fraud. But I see Medicaid routinely go back five years in certain states and some Medicaid programs use extrapolation, which can be extremely daunting because now they're going to take if 2 % of your claims are errant, they'll go back five years. Well, we pay you $10 million. Now it's 2 % of million, which is a lot of money. So having and being very careful, most PBMs and there are a lot of state PBM reform have tried to limit how long they go back. I love Louisiana's law that restricts a PBM can only go back as long as the billing window is open. So that essentially allows the billing window be open much longer for pharmacies because they can only audit during that timeframe. That's a great state law that I love to see, but traditionally two years. Like if it's beyond two years, it's probably an exception unless it's Medicaid and Medicaid will go back five or unless you've got OIG or some audit contractor coming in for big suspicion of fraud and that's where I, you know we talk about like being proactive. It's just the way I've always done it. It's always worked for me, and it always works until you get handed a PBM audit and they will be very quick. One of the challenges too, is it's not just financial anymore, right? Where, hey I'm going to pay back $10 ,000. Yes, it hurts. If you have the resources, it hurts. I'm going to move on. We're seeing more terminations, right? If you're failure to collect copays, they can lead to network terminations, which is, can be a domino effect. If you get terminated from any PBM network, you have to notify the other PBMs and they're going to come looking and wanting, and why did you get terminated? And then they're going to come and audit as well, looking for those same things. So, getting terminated from a network can, I don't want to say it's a death sentence, but it can be disastrous for a pharmacy. And so, we see all the time, and I got an email this morning, actually it was late last night. I need an immediate corrective action plan. We're seeing these being required from pharmacies based on circumstances that guys, he only has a $2,500 invoice shortage at the end of the day. And he's in New York. He might be in a heat zone, which is prone to potential FWA. $2 ,500 is not a bad invoice reconciliation audit. I consider that a very good audit, frankly. And they're demanding an immediate corrective action plan. It scares a lot of owners. Because it's not about the $2,500 at that point. They're not happy about it. They're willing to move on. It's about, I want to make sure I don't get terminated, that they accept my corrective action plan, and those kinds of things. They're very much big bullies, threatening and scaring pharmacies. And we guide them through, here's what a corrective action plan should look like. Caremark does lay out some guidelines for this. And then making sure that they can get that accepted so they don't fear termination.
Scotty Sykes, CPA, CFP®: Got that right. Trent, what about, you mentioned the copay collection. I've seen this where a pharmacy, you know, the patient can't pay the copay and they put it on account, AR account, you know, they make efforts to collect, they make efforts to collect and eventually they just write it off. I mean, what's a kind of a best practice there in your opinion?
Trenton Thiede: Yeah, absolutely. I think Caremark, I would say that Caremark probably is the most explicit both on, if anyone wants to read it, Caremark is most explicit about copay collection and about kind of this area of accounts receivable, let's say from a patient, first party charge or whatever a pharmacy will call it. One of the key things is, and I think you said it, Scotty, is efforts to collect. And to what point does the pharmacy have documentation that they've tried to collect versus it's just a farce. I've just put it on an account, but we're never really going to collect. I'll just put it over there and we'll waive it after 90 days. What would suffice in my opinion on a CareMark Audit is if they put it on an account, patient doesn't have the money at the time. And there are certain areas, right? There are OIG safe harbors for waiving copays based on certain circumstances for Part D and LIS and Medicaid, but setting that aside, you've got a $50 copay for insulin and the patient needs it or 35 now and the patient needs it and they're not able and independents right? Their hearts bleed for patients and taking care of patient care. So, they're going to give them the meds no matter what. So, they put it on an account. What Caremark or other PBMs will want to see, do you have policies and procedures related to that, right? To your AR system? What are your policies and procedures? Do you bill them monthly? Right? A good policy would be the first of every month. I'm going to send a bill to Mrs. Jones. To let her know that we have a $35 outstanding balance month after month, month one, month two. And then potentially after month two, I place a couple of calls and say, hey, we still have an outstanding balance. I'm required to collect this. Your insurance may request the documentation, know, and kind of coaxing that patient into hopefully making payments or coming in to pay it. And then at, you know, the potential 90-day interval, determining whether to write that off. And then, you know, going forward, are you going to cap that? Right. Cause I think there's a couple of components to a policy is like how much leeway are you going to give a patient in terms of how much, you know, total limit and what happens if you cap them, are you never going to let them charge again? Right. If they won't pay their copay, are you going to restrict them from charging some of those policies in there? But Caremark requires, you have to show efforts to collect before the audit. If you don't have anything documented that you've sent out routine statements or made calls and they audit you and you haven't collected, you're going to be in a rough spot.
Scotty Sykes, CPA, CFP®: Policies and procedures proactive that's the name of the game with the audits I'll tell you that is the name of the game well Trent what else anything else you want to cover before we...
Trenton Thiede: I'll give a couple other good tips, I think, to think about it. I think for owners, one of the things that we see Optum, and talking about proactive, one of the big things we see Optum do is going after products that must be dispensed in the original container. We talk about it all the time. I'll give you a couple of examples. Linzest drug, and Biktarvy. So HIV, and one's for chronic idiopathic constipation. But these are drugs that from the manufacturer must be dispensed in the original container. And it's an easy algorithm for PBMs. So Linzest comes in a 30 count, if you're dispensing in 28 count, it's so easy, right? It's an easy algorithm. A 28-day supply, there's no way you gave it in the original bottle. That's $3 ,000 a fill times 11 months times all of your patients. That can be six figure audits. So, I caution a lot of pharmacies that do compliance packaging, there's nothing wrong with that. When you're doing 28 -day, it can be a huge problem for dispensed and original containers. So, some systems are set up to do 28 -day. If you're doing 28 -day, you have to carve out your dispensed in original container products. We have a list that we've looked up in what we see most commonly audited, but there is little ability to recoup. We've seen some effort, but if you don't dispense in the original container for a product that says it, and these are all high dollar, super expensive, common unit of use, really kind of containers, pharmacies get torched. They're trying to help the patient by giving them compliance packaging, trying to improve adherence, all the right things.
Scotty Sykes, CPA, CFP®: So can you not compliance package those?
Trenton Thiede: You should not, right? They're exempt, even in a skilled environment like LTC where you have a 14 day, you're exempt from putting that into a short cycle situation. Nursing homes, in my experience working in LTC, they hate it. I can guarantee you it leads to non -adherence, missing meds because they're in a bulk area, this medication cart being pushed down the hall, and they only give what's in the bubbles. What I'll tell you is the algorithm looks for quantity, right? So again, I'm not clinically there's a concern right from the manufacturer, from the FDA. But if you're dispensing 30 days, they can't detect whether or not your compliance packaging, right? 28 days, 31 days, if you're doing calendar months, that's where pharmacies get in trouble. And again, it's about being proactive, right? It's about making the right decisions today so that they don't come back a year or two years from now. It's very frustrating because how easy would it be for Optum or Caremark or anyone else to put in a reject to say, we only allow this to be a 30-day supply. They much rather entrap you, have you bill thousands, tens of thousands of dollars in claims, and then just come back and recoup it all. They're by and far complicit with that. It's so frustrating and owners know it and they see it and it's just like printing money for them.
Scotty Sykes, CPA, CFP®: That's interesting. That's a good point.
Trenton Thiede: Yeah. The other thing I'll mention coming out of the pandemic is thinking about mailing and delivery restrictions by PBM, right? During the public health emergency, a lot of pharmacies got very accustomed to not collecting signatures when delivering things like that or taking a picture. And the PBM provider manuals are very specific about whether or not you can mail because there are mailing restrictions. What happens when you're mailing out of state? They're happy to jump on board with non -resident pharmacy licensure issues. What happens when you're delivering through contracted delivery? Those are all things pharmacies need to be aware of if they're doing heavy delivery or mailing. The PBMs very much look for those kinds of issues. again, they're very much entrapment. They don't call it out. They'll let you bill and build your claim liability. And then a year or two years from now, they'll send out an auditor to say, I think you've got some issues here, and then they're going to come and recoup all that. They're not proactive. They want it. They're happy. They're proactive in increasing recoupments.
Scotty Sykes, CPA, CFP®: They don't want to help. They're just gonna come get you a little later and get the gotcha.
Trenton Thiede: It's very much, yeah, it's very much a gotcha, unfortunately.
Scotty Sykes, CPA, CFP®: It is. Well Trent, we appreciate you getting on and spending some time with us today. I Reckon we'll see at NCPA.
Trenton Thiede: Yeah, absolutely.
Scotty Sykes, CPA, CFP®: So I have to say hey, but we again appreciate you hopping on and any questions
Bonnie Bond, CPA: And everybody out there, don't wait till the day the audits due. I'm gonna, you haven't told me that. I'm just gonna guess that that's probably a preference for you guys. We have some of that too. People contact us and want their tax return done, you know, in a day or two. So, it's not, you know, preferred...
Scotty Sykes, CPA, CFP®: Doesn't really work that way so anybody listening in if you don't have a practice management or point of sale or yeah, might want to start there. Trent, thanks again for hopping on and we'll see you out on the trade show floor
Bonnie Bond, CPA: Thanks Trent.
Trenton Thiede: Hey guys, my pleasure. Thanks a lot for having me.
