Medicare/ Medicaid Pharmacy and Office Audits
The Law Offices of Joseph J. Bogdan, LLC

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Illinois Medicare Pharmacy Audit Defense Attorney

Illinois Medicaid Audit Defense Attorney

Medicare and Medicaid Pharmacy and Office Audits in Illinois and Throughout the U.S.

The rules for compliance with Medicare and Medicaid are highly complex and ever-evolving. With ongoing changes to the healthcare landscape and an uncertain future, it is difficult for pharmacies (particularly those that are small and/or independent) to keep up with these changes. The Centers for Medicare and Medicaid (CMS) has oversight over the Medicare Part D program, and conducts office and field audits of pharmacies to ensure they are in compliance. If you are a pharmacy facing a CMS audit, it is important to have skilled legal counsel in your corner to guide you through the process.

For over 16 years, the Law Offices of Joseph J. Bogdan, LLC has successfully represented countless clients for Medicare/Medicaid pharmacy and office audits in Illinois. Joseph Bogdan is both an attorney and a registered pharmacist. He also has a Pharmaceutical Doctorate degree and is a board member of the Illinois Pharmacist Association. He is frequently called upon as an expert witness for pharmacy-related legal matters, and he teaches Pharmacy Law at three universities in the Chicago area.

Attorney Bogdan's extensive background with both the legal and medical field gives him unique insights into the legal issues pharmacists commonly face when dealing with various governing entities. He helps pharmacists with a wide range of legal matters, including but not limited to Illinois Board of Pharmacy licensing issues, PBM pharmacy audits, Drug Enforcement Agency (DEA) actions, buying and selling of pharmacies legal representation, and Medicare/Medicaid audits.

Types of CMS Pharmacy Audits

There are two general types of audits performed on pharmacies that participate in the Medicare Part D prescription drug program; office audits and field audits.

Office Audits: An office audit is an automated review of the claims data submitted by the pharmacy. This may include the review of information such as payment reports, prescription patterns, drug utilization reports and other data to detect any red flags. If any unusual patterns are discovered, they may follow up with the pharmacy for additional information or take further actions.

Pharmacy Field Audits: A field audit is when a CMS field auditor visits the pharmacy in person to observe the operation, review prescriptions, and ensure compliance with Medicare Part D rules and regulations. Typically, a field auditor may examine the following areas:

  • Pharmacy/Pharmacist Licenses
  • Health Insurance Portability and Accountability Act (HIPPA) Compliance
  • The General Safety and Cleanliness of the Operation
  • Medicare Part D Poster Displays
  • Security Measures used for Controlled Substances
  • Substance Refrigeration Temperatures
  • Waste, Fraud and Abuse Training Documentation
  • Compliance with Other CMS Rules and Regulations

Medicare/Medicaid pharmacy and office audits can result in consequences ranging from a simple warning to up to 100% of your CMS reimbursements being forfeited, the latter being enough to put many smaller pharmacies out of business. If you have received notification of any type of CMS audit in Illinois, you cannot afford to leave the results of the audit to chance. For a personalized consultation with Attorney Bogdan, contact our office today at 630-310-1267.

Illinois State Bar Association DuPage County Bar Association Illinois Pharmacists Association American Pharmacists Association 10.0Joseph John Bogdan
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