1. Defined program ownership
Every major program activity should have an accountable owner, a backup, a review frequency, and clear evidence that the review occurred. Governance should extend beyond pharmacy when registration, eligibility, billing, contracting, or patient definition decisions involve other departments.
2. Current policies that match practice
Policies should describe the workflow that staff actually follow. A policy that is technically comprehensive but operationally inaccurate can create risk because it does not demonstrate effective oversight.
3. Routine transaction testing
Covered entities should test representative transactions across locations, payers, providers, mixed-use logic, Medicaid billing, and contract pharmacies. Testing should include both eligible and ineligible scenarios.
4. Reconciled source data
Registration records, provider lists, locations, contracts, accumulator configuration, and claims data should be reviewed together. Material differences should be investigated and documented.
5. Corrective action follow-through
Findings should have an owner, due date, documented resolution, and validation step. Closing the task is not the same as proving the underlying risk was corrected.
BPRx can help assess current practice and build a practical improvement plan.
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