The Maryland Department of Health did not audit pharmacy claims for three of its four fee-for-service pharmacy programs, leaving approximately $674.5 million in fiscal 2025 claims without routine reviews for fraud, waste, abuse and billing violations, according to a July 13 audit from the Maryland Office of Legislative Audits.
The agency agreed with the audit’s recommendations and said it plans to establish routine pharmacy claim audits through its existing pharmacy vendor contract.
Here are five things to know:
- The three unaudited programs accounted for about 95% of the state’s $710.2 million in fee-for-service pharmacy claims paid in fiscal 2025.
- Auditors said the lack of pharmacy claim audits was identified in the state’s two previous audit reports dating back to 2020 and remains unresolved.
- Auditors flagged pharmacies with low claim reversals. The report identified 172 pharmacies with $161.7 million in paid net claims that reversed fewer than 5% of claims, compared with the program average of 23%. Auditors recommended the state investigate the pharmacies.
- Prior audits uncovered recoverable payments. Audits of the Maryland AIDS Drug Assistance Program for calendar years 2021 through 2023 identified $840,000 in claims that should have been recovered.
- MDH said it intends to modify its existing pharmacy vendor contract to add routine audit services, with implementation anticipated by July 1, 2027, pending funding.
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