While PBM audits have always reviewed providers records to confirm the collection of copayments, in the past few months Frier Levitt attorneys have observed an uptick in not only the volume of copayment-related discrepancies alleged against pharmacies, but also an increased scrutiny with respect to the documentation submitted by pharmacies to reverse these discrepancies. Pharmacies’ awareness of such a shift in PBMs auditing is crucial to avoiding unnecessary recoupment.
PBMs’ concern with the collection of copayments is nothing new. During audits, pharmacies are typically asked to provide receipts demonstrating the remittance of copayment and patients themselves are also contacted to confirm that the copayment they paid correlates to the copayment disclosed by the pharmacy. Per PBMs, these measures are taken to ensure that pharmacies are in fact collecting the appropriate copayments from patients in order to confirm the legitimacy of the claims reimbursed by PBMs. Accordingly, failure to properly document the collection of copayments from patients may inadvertently imply to PBMs that a pharmacy is continuously billing and dispensing prescriptions to patients without collecting copayment. However, while receipts and patients’ explicit confirmations of their remittance of copayment used to satisfy PBMs, it seems to be that is no longer the case. Recently, PBMs have requested that pharmacies now submit documentation that further demonstrates the validity of the underlying transactions, and specifically that the pharmacies themselves are receiving the funds at issue. While receipts and patient signature logs confirming the transactions should still be maintained, pharmacies should also be prepared to provide credit card merchant reports clearly demonstrating their receipt of the funds at issue, or, in the case of cash transactions, bank statements which show that the cash was in fact deposited into the proper account.
Additionally, as often is the case in PBMs, the types of conduct they require or prohibit are often at odds with common pharmacy practices. While PBMs may require pharmacies to carefully document every instance of copayment collection, there are very commonplace situations in which copayments are not collected which should not raise concerns to PBMs. Specifically, pharmacies often waive copayments for patients who cannot afford their prescriptions. While PBMs may permit the waiver of copayments, pharmacies should be sure to only do so in accordance with a financial hardship policy following an appropriate, individualized assessment of financial hardship, and in compliance with the terms of the PBM agreements and manuals. For example, PBMs restrict the types of situations in which pharmacies may waive a copayment. Most commonly, PBMs strictly prohibit pharmacies from waiving copayments except for cases where a pharmacy determines that a patient is in financial hardship. Therefore, pharmacies should be sure to review the terms and conditions of their PBMs manuals before collecting or waiving any copayment, or otherwise risk being subject to recovery or further action.
How Frier Levitt Can Help
Whether your pharmacy has recently undergone an audit, received audit findings alleging improper copayment collection, or is working to implement a copayment policy to avoid such complications in the future, Frier Levitt can help. Please contact us to speak with an attorney today.
