Practice / Medicare Fair Price Audit
Audit 04
Medicare Fair Price Audit
The negotiated price, checked against your own files: what you loaded, what you bought, what you billed, what came back.
Draft — verify Medicare negotiates a maximum fair price on selected drugs under the Medicare Drug Price Negotiation Program. A negotiated price only reaches your books if your own files carry it, your purchasing reflects it, your claims agree with it, and the money owed back to you actually arrives. Each of those is a different system, maintained by a different team.
This audit is a file review. We are not renegotiating anything and we are not making a legal determination. We read your files against each other and tell you where they stop agreeing, in evidence you can hand to your compliance officer.
What the file review covers Loaded, purchased, billed, returned
- What was loaded. Whether the negotiated price for each selected drug is present and current in the drug file and the charge master, with a date and an owner on the last update.
- What was purchased. Whether purchase records reflect the price you were entitled to, and where they do not, which step produced the difference.
- What was billed. Whether claims and billed amounts on selected drugs line up with the price carried in your own files.
- What came back. Whether the credits, chargebacks or refunds owed against the negotiated price were received, reconciled and recorded, unit by unit on a sample.
- Whether you can show it. A dated evidence pack a second person can reproduce without the first one in the room.
Draft — verify Specific program dates, drug lists and effective periods are confirmed against current guidance at the start of an engagement rather than quoted here, because they move. Compliance and legal determinations are confirmed with your own counsel and compliance officer.
Where it touches the 340B work Two prices, one unit
Draft — verify The same unit of the same drug can sit inside more than one pricing arrangement, and the systems that decide which one applies are the same systems the 340B audit already reads: the drug file, the accumulation logic, and the claim. If you are running both programs, the position you take on a unit needs to be consistent, documented, and reproducible on request.
We check the position rather than set it. Where the answer is a legal or compliance determination, we say so and it goes to your counsel and your compliance officer, which is the same boundary we hold everywhere else in the practice.
The Deliverable Model
What you get, and in what order.
Draft — verify Medicare negotiates a maximum fair price on selected drugs, and the price only helps you if your own systems know about it. This audit is a file review. We look at how the negotiated price is loaded into your drug file and your charge master, whether what you purchased and what you billed reconcile against it, and whether the credits and chargebacks you were owed actually arrived. Where the file says one thing and the claim says another, that is the finding.
What you get, in order
- 01Audit Results
The findings, written to evidence-file standard rather than to slide standard. Every one carries a severity, a named owner and a due date, so your compliance and internal audit teams can use it as evidence instead of filing it as opinion.
- 02Operational Changes
What gets fixed, where, and by whom. Your team owns the daily work. We name the change, the owner, and the threshold it has to hold to, and we say plainly what each fix is worth against what it costs to make.
- 03Ongoing Audits
Scheduled re-checks at month six and month twelve to confirm the fix held. Anything still open carries forward with its age attached, so nothing quietly ages out. If the numbers did not move, that finding is the deliverable.
- 04Ongoing Support
A standing accountability call on a cadence you set. We work the open items, look at what has drifted since the last audit, and pressure-test the changes you have coming before they get built rather than after.
The Other Three
Each one runs on its own, or alongside this one.
Compliance discipline. This work follows the same HIPAA-aware, BAA-ready discipline as the rest of the NoBullStrategy practice, with PHI handled on a minimum-necessary basis and de-identified or synthetic data used wherever the work allows. A Business Associate Agreement is executed before any protected health information is accessed. NoBullStrategy does not practice medicine and does not provide legal advice; compliance, coding, and legal determinations are confirmed with your counsel and your compliance officer.
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