In a recent trend, pharmacies have begun receiving notices of termination not for billing errors or audit findings, but for claims inactivity. Specifically, several Pharmacy Benefit Managers, or PBMs, have been terminating pharmacies solely because they have not submitted claims to the PBM for an extended period of time. Unfortunately, given the current climate with the ongoing COVID-19 pandemic, several pharmacies have been forced to keep limited hours or to temporarily close down to ensure the safety of their employees, staff, and patients. Despite the proactive and cautious measures that pharmacies have been required to undertake, PBMs have exercised little known provisions in their agreements to terminate these pharmacies for not submitting claims for the PBM’s patients for a period of time (typically between 60-180 days). However, and importantly, PBMs have not considered that several pharmacies faced with this predicament also took actions to ensure that their patients would not face an interruption in service by transferring their prescriptions to another pharmacy that was able to service their needs.
Once terminated, in order to be readmitted into the PBM’s networks and continue servicing patients, pharmacies are required to undergo credentialing again. This would cause pharmacies to experience significant lapses in their ability to service patients because of the time it takes to reapply and await their applications to be processed, which is generally a significant period of time, particularly for pharmacies located in HEAT zones. In addition, pharmacies might be required to accept new network terms and conditions that they might have otherwise not been subject to. For example, a pharmacy that was previously permitted to process compound prescriptions may not be able to fill or dispense any compound prescriptions upon credentialing after a termination under these circumstances.
How Frier Levitt Can Help
That said, it is increasingly important to ensure that pharmacies are aware of what their requirements are under their respective provider agreements, but more importantly to ensure that they are not being wrongfully terminated. Contact Frier Levitt to speak to an attorney today.
