The Basics

This very important standard requires that your organization have a process by which it may protect consumers from a participating pharmacy that poses a health risk to consumers or promotes fraud and abuse.  The process must provide for an expedited investigation and access by the suspended pharmacy, after the suspension, to the dispute resolution mechanism described in the previous page.  This standard is particularly important because it is a consumer safety mechanism, always at the top of the accreditation priority list.

Management Tips

Typically, organizations address the situation by empowering a senior clinician within the organization with a great deal of flexibility to suspend a pharmacy that poses a health or fraud risk.  URAC expects that senior clinician to have broad discretion that he or she will exercise when convinced of the health or fraud danger.  That discretion is counterbalanced by the fact that pharmacy, after suspension, will still have access to dispute resolution process.  The key here is that the senior clinician be able to do what he or she needs to do to protect consumers without getting bogged down in time-consuming dispute resolution procedures.

URAC Accreditation Tips

Most of the elements of the standard are mandatory.

The key document for the standard, of course, is the policy and procedure and/or pharmacy provider manual that describes the dispute resolution process, including the suspension mechanism required by the standard.

During the on-site review, the reviewer will ask for a list of any pharmacies that have been suspended under this mechanism.  It is very likely that you have none to report, but if you do, the reviewer will want to see the files.  In addition, if the committee is involved at any point in these processes, the reviewer will want to examine committee meeting minutes.   Finally, it will be very important that, during the interview process, the senior clinician with the authority to suspend pharmacies understands his or her responsibility to act expeditiously.