This past week, Humana announced a 46% decrease in profits stemming largely from the costs associated with the ongoing Aetna merger, which is anticipated to close in the second half of 2016. As part of the transaction, Aetna is set to acquire Humana, but the deal is still undergoing regulatory approval.
In the meantime, as evidenced by this recent report, Humana has had to expend significant resources to undergo the due diligence and approval phases in advance of the completion of the merger. As a result of these costs, pharmacies in Humana’s networks are seeing increased trends in auditing and payment recoupments from the pharmacy benefit manager, potentially in response to these added costs and decreased profits. Over the last several months, Humana has drastically stepped up its focus in auditing and reviewing network pharmacies on a variety of issues. Humana has rolled out new auditing and recoupment techniques not previously utilized by the PBM, and has focused on a variety of new topics, including off-label uses, FDA approval of medications, and patient signature requirements. By virtue of these increased audit tactics, pharmacies have faced millions of dollars in increased recoupments from the PBM.
Pharmacies participating in Humana’s networks must be cognizant of these changing audit trends, and must take proactive steps to remain in compliance with Humana’s contractual requirements and stay ahead of the curve. Frier Levitt routinely represents pharmacies in connection with Humana audits and payment recoupments, and can assist your pharmacy if you are facing a similar issue. Importantly, many State laws afford fair audit protections to pharmacies which can temper the ability of a PBM to conduct sweeping audits and recoupments. If you are facing an audit or recoupment from Humana, or any other PBM, contact Frier Levitt today.
