Comprehensive Audit Prevention Services (CAPS)

The CAPS Mission

To provide independent pharmacies with the knowledge and tools to see audits for the purpose they serve, while minimizing the impact of recoverable monies by health plans. Pharmacy Benefit Managers (PBMs) and processors have a responsibility to their health plans to manage their complete program costs. The Centers for Medicare and Medicaid are included among these as the largest, especially with the growing increase in drug costs. Pharmacy audits are a means to maintain the PBM/processors cost and value to those plans and ensure or prevent fraud, waste, and abuse.

Pharmacy audits have become more aggressive and invasive to the independent community pharmacy. CAPS is here to help!

Comprehensive Audit Prevention Services (CAPS) was started to assist pharmacies with audits from Pharmacy Benefit Managers and the organizations they contract to perform audits.

Established by a former auditor, CAPS is designed to ensure that independent pharmacies are educated on the audit process; know how to prepare for an audit; what the expectations of the audit will be; and understand how to respond effectively to an audit. CAPS will even put a staff member on-site during an audit if a pharmacy requests the help!

The pharmacy benefit industry continues to grow. More claims are processed by third party payors, including Medicaid. This leads to programs by PBMs/processors to recover monies whenever and wherever possible to demonstrate to contracted plans their usefulness and ability to save costs. With the government now the largest consumer of health care, their history is to review what they have paid for. The ten (10) year window that CMS incorporated is an expansive time to be able to reclaim monies.

CAPS is dedicated to counteracting the impact of large organizations such as PBMs/processors. As a professional organization, CAPS represents independent pharmacies and can gain more traction, especially with the knowledge and education to pharmacies, against the “that’s how it is” mentality portrayed by the audit departments and outsourced agencies from pharmacy benefit managers and processors.