Recently, Frier Levitt was successful in reversing one hundred percent (100%) of audit findings issued by a major PBM against a Texas-based pharmacy. During the audit, the PBM heavily scrutinized the Pharmacy’s supporting documentation and asserted that the responsive documents were inadequate merely because they did not include irrelevant personal information pertaining to the patients. Under Frier Levitt’s guidance, the Pharmacy was able to correct the documents and draft an appeal response highlighting the PBMs violation of applicable state law and address the PBM’s wrongful conduct. After receiving the appeal response, the PBM reversed every alleged discrepancy along with 100% of the amount at issue.
PBM Audits and Supporting Document Requirements
PBMs often use routine audits as an attempt to seek unwarranted recoupment funds from their contracted providers. PBMs have implemented a high standard of review over the documents required to overturn discrepancies. Consequently, even when discrepancies do not exist or the documents previously provided by the pharmacy are sufficient to verify the legitimacy of the claim, as shown in this matter, PBMs will refuse to reverse any alleged discrepancies in the absence of the precise details in the documentation they requested. Specifically, Frier Levitt has experienced PBMs refusing to reverse claims requiring prescriber attestations where the signed attestation was adequately supplied using the correct criteria but lacked the printed name of the prescriber above the signature. Therefore, pharmacies must implement specific policies and procedures designed to retain the types of documents PBMs request during audits to avoid any unwarranted discrepant findings.
Additionally, it is not only important for pharmacies to maintain specific policies and procedures, but they must also be rather comprehensive and robust. Different PBMs often vary as to the documents they require during an audit. For example, for copay discrepancies, some PBMs require much more than just a member attestation. Instead, they will require receipt of bank statements to verify cash payments and credit card merchant reports to verify credit card payments. Likewise, there are different standards across the industry as to what is needed for claims requiring a prescriber attestation. Some PBMs will accept individualized attestation templates as long as they are completed on the prescriber’s letterhead. On the other hand, other PBMs will provide a provider attestation template and will refuse to reverse a claim with any other template.
Further, when faced with discrepancies in PBM audit results, pharmacies must be diligent in utilizing the contractual appeal process outlined in their agreements and PBM manuals to combat any and all audit findings, regardless of the amount at issue. Failure to contest discrepant audit findings, even ones that appear to have insignificant consequences, could lead to a pharmacy’s termination from a PBM network down the road. Such a pattern has been identified where PBMs track each pharmacy’s audit history and rely on past audit results as justification for terminating an otherwise compliant pharmacy. Thus, even though smaller audit amounts may not seem to be “worth” disputing, failure to do so may serve as the basis for severe PBM sanctions in the future, including, but not limited to, network termination. By retaining legal representation and taking prompt action, pharmacies not only avoid significant economic and reputational harm, but ensure continued services to their patients.
How Frier Levitt Can Help
Regardless of the size of your pharmacy or the amount at stake, Frier Levitt is ready and able to assist you in successfully challenging PBM abuse of your pharmacy. Our life sciences attorneys are prepared to provide guidance as your pharmacy prepares for audits as well as take an aggressive approach to fight for your rights following a PBM audit. If you have questions or need help fighting adverse PBM actions, contact us to speak to an attorney.
