How to Defend Your Pharmacy During a Qlarant Investigation

Pharmacies targeted in Qlarant audits and investigations can face severe consequences. Beyond recoupment liability for improperly billed amounts, pharmacies can also face denial of pending claims, prepayment review, and other financial consequences. If Qlarant uncovers significant evidence of fraud, it may also refer a pharmacy to CMS for civil or criminal prosecution.

With this in mind, here is an overview of some of the key steps involved in defending against Qlarant investigations and audits:

Knowing What to Expect

Qlarant gathers information during its investigations in multiple ways. In addition to relying on data received from CMS, Qlarant also sends investigators to targeted pharmacies, and it deploys what it refers to as “Jump Teams” to hit the ground running. By preparing for when Qlarant investigators come on-site, pharmacies can ensure that their personnel does not inadvertently make mistakes that end up having costly consequences during (or after) the investigation.

Having Supporting Documentation on Hand

During Qlarant investigations, if pharmacies cannot produce documentation that substantiates their Medicare or Medicaid billings, this will lead to a presumption that no such documentation (and no such substantiation) exists. While pharmacies need to be careful about the records they provide to Qlarant, they also need to be prepared to supply all necessary documentation during the investigative process.

Establishing Internal Roles for the Investigation

Pharmacies often run into unnecessary issues during Qlarant investigations as a result of failing to establish internal roles during the investigative process. All personnel, from the pharmacy’s executives and pharmacist-in-charge to technicians and administrative employees, need to have a clear understanding of what they should do—and what they should not do—while the pharmacy is dealing with Qlarant. This includes adhering to an internal chain of command, funneling all communications through appropriate high-level executives and employees, and only allowing investigators access to electronic and paper files upon clear direction from the pharmacy’s leadership or outside counsel.

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