How an FWA review differs from a routine audit
- A routine audit checks documentation for a sample of claims under the PBM contract.
- An FWA review looks for patterns, for example in prescribers, products, quantities or billing over time.
- It may be opened by a PBM’s investigations unit, a plan sponsor, a government contractor or a state program.
- It may ask for more records over a longer period, and some FWA matters can have legal consequences.
Compliance basics most network pharmacies keep
- A written compliance policy and a named person responsible for it.
- FWA training for staff, with records of who completed it and when.
- Checks that employees and prescribers are not on federal exclusion lists, done on a regular schedule.
- A way for staff to raise concerns, and a record of how concerns were handled.
- Organized prescription, dispensing and purchase records. See the audit documentation checklist.
If you receive an FWA-related request
Read the letter closely, note who sent it and what it asks for, and respond within the time it states. Because FWA matters can carry legal consequences, many pharmacies speak with a licensed attorney before responding. Pharma360 provides legal representation through licensed attorneys under a separate scope, while the consulting team organizes the records. For the wider picture, see Medicare Part D pharmacy audits.
Keeping FWA training and checks on record
When a PBM or plan sponsor asks a pharmacy to confirm its FWA program, it usually wants evidence rather than a statement. Keep a simple file with the current compliance policy, the name of the person responsible, the training materials used, a sign-in or completion record for each employee, and the dates and results of each exclusion-list check. Review the file on a set schedule, add new hires promptly, and note any changes to the policy. A file like this is quick to send when it is requested, and it also helps a new manager understand what the pharmacy already does. If you are not sure what your contracts require, ask the PBM or plan sponsor in writing and keep their answer with the file.
Frequently asked questions
What does FWA stand for in pharmacy?
Fraud, waste and abuse: the terms Medicare, Medicaid and PBMs use to describe different kinds of improper payment.
Do pharmacies need FWA training?
Pharmacies in Medicare Part D networks are generally expected to train staff on FWA as part of a compliance program. Check your network contracts for the specific requirement.
Is an FWA review the same as being accused of fraud?
No. An FWA review looks at claims and patterns. Many reviews focus on documentation and billing accuracy, but because some can have legal consequences, take every request seriously.
Can Pharma360 help with an FWA review?
Yes. The consulting team organizes and reviews the records, and legal representation is available through licensed attorneys when it is needed.
Official sources
Talk to Pharma360
Want your FWA compliance basics reviewed, or help with a request? Pharma360 supports independent pharmacies by phone and Zoom. See our medicare & medicaid audits service, call (267) 809-2396, or request a call back. Your first phone or Zoom consultation is free, one time. Philadelphia-based, serving independent pharmacies in all 50 states.
Published by Pharma360 Solutions LLC · Updated . General information for pharmacy owners, not legal advice. Deadlines and requirements are set by your PBM contract and audit notice; always check the notice.