Independent pharmacists tell committee that Medicaid audit rules and extrapolation penalties threaten small pharmacies

Summary

Independent pharmacists told the Human Services Committee that Connecticut’s Medicaid audit system — and the practice of extrapolating sample errors across multi‑year claim universes — is producing runaway recoupments that can threaten small community pharmacies after clerical errors or software misconfigurations.

(continued) recoupments use broad extrapolation.

Independent and association witnesses described cases in which Medicaid desk audits found relatively minor documentation or clerical problems — for example, missing patient signatures after an emergency change in protocol — and then applied extrapolation across a multi‑year universe of claims. Because Medicaid reimburses most drug costs at or near pharmacies’ purchase price (via NADAC) and pays a relatively small dispensing fee, witnesses said extrapolation of entire claim amounts (not just the $10‑$11 dispensing fee) creates massive recoupments that can exceed hundreds of thousands of dollars for a small pharmacy.

Pharmacists described their experiences: Grieves Pharmacy in Darien reported a proposed ~$705,000 recoupment tied to a software setting that had not been…

Independent pharmacists tell committee that Medicaid audit rules and extrapolation penalties threaten small pharmacies

Summary

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