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Cross-Terminations of Commonly-Owned Pharmacies Becoming Increasingly Common

There is a growing trend of pharmacies that are being terminated from pharmacy networks by Pharmacy Benefit Managers (PBMs) due to the pharmacy's affiliation with providers who have been previously terminated from the PBM's pharmacy network. PBMs are targeting pharmacies that have relationships with terminated individuals or pharmacies. This means that your pharmacy could be subject to termination if it has common ownership, hired employees, maintains officers, or directors, who...

Frier Levitt Successfully Reduces Multiple Overpayment Demands for Three Medical Practices

Frier Levitt recently represented three medical practices faced with significant overpayment demands. Insurance companies have been auditing practices at a feverish pace that has only increased over the past few years. When audit "failures" can be based on simple documentation errors, an oversight in credentialing, or a multitude of other arbitrary reasons, overpayment demands are a near certainty.  Due to payors' use of extrapolation, audits are leading to very large...

PBMs Taking Hard Stance Over Use of Patient Assistance Programs

Recent enforcement actions over allegations regarding assisting pharmaceutical manufacturers to pay improper kickbacks to Medicare beneficiaries are not the only issues currently impacting Patient Assistance Programs (PAPs). PBMs are also taking an increasingly hard stance over the use of PAPs by specialty and retail pharmacies across the country. Some PBM Provider Manuals include explicit terms and conditions regarding the use of financial hardship policies, but many are silent with regard...

Sentara Hospitals’ $2.175 Million HIPAA Settlement

Virginia-based Sentara Hospitals has agreed to a $2.175 million settlement with the Office for Civil Rights at the U.S. Department of Health and Human Services (OCR) for alleged violations of the Health Insurance Portability and Accountability Act (HIPAA) on behalf of its ten hospitals. On April 17, 2017, the OCR received a complaint alleging that an incorrect hospital bill, containing another patient's Protected Health Information (PHI), was mailed to a...

Pharmacy ALERT: PBM Re-credentialing Requests and Performance Reviews

As the calendar year comes to an end, Pharmacy Benefit Managers (PBMs) often review pharmacies that participate in their networks. Such reviews may include an evaluation of past audit performances or any past adverse action taken against the pharmacy, or such reviews might include requesting the pharmacy to undergo "re-credentialing." Pharmacies that are asked to undergo re-credentialing are often asked a series of questions associated with general ownership structure, location...