Recently, Frier Levitt attorneys Harini Bupathi, Esq. and Benjamin Youssef, Pharm.D., Esq., assisted an Oregon-based Physician Practice client in challenging two major Pharmacy Benefit Manager (“PBM”) audit findings simultaneously, and successfully reversed approximately $300,000.00, 100% of the amount at issue. In one of the audits, the PBM asserted the pharmacy’s directions on the prescription records were allegedly different from the computer record, and that the Pharmacy submitted documentation where the signature obtained allegedly exceeded the 14-day contractual timeline. Under Frier Levitt’s guidance, the dispensing physician practice gathered significant supporting documentation to disprove all of the PBM’s allegations, leading to the PBM reversing the full amount of the discrepancies when it issued the final audit findings. Of note, where the physician is also dispensing the medication to the patient, some of the discrepancies that the PBM alleged were inapplicable, in particular, any issues regarding the directions for use not being clear to the patient.
That said, providers must be aware of the specific types of documentation that each of their PBMs require to address adverse audit findings. When challenging any audit discrepancy, supporting documentation that verifies the legitimacy of the claim at issue and refutes the PBM’s allegations must be submitted. Here, the practice submitted copies of the prescription records, prescription labels, and signature logs, establishing both the legitimacy of each claim at issue as well as the patient’s receipt of their necessary medications. Additionally, the practice submitted documentation demonstrating that patients had issues with picking up their prescriptions in a timely manner, to no fault of their own. Therefore, practices who are contracted with a PBM must ensure they frequently maintain proper documentation of prescription records, prescription labels, signature logs, monthly statements issued to patients, cash collected to satisfy copayments, and maintain documentation that even ties the cash deposit to the relevant claims.
This matter further demonstrates the importance of combating any and all PBM audit findings, as PBMs assert unnecessary discrepancies to use audits as a source of revenue rather than ensuring compliance with applicable laws and contractual obligations. PBMs will use multiple adverse audit findings to justify terminating physician practices and pharmacies from their network, so it is crucial for providers to appeal PBM audit findings and attempt to reduce the amounts at issue to the fullest extent possible. Thus, even seemingly “insignificant” amounts should be appealed to avoid additional future adverse actions by PBMs.
How Frier Levitt Can Help
Frier Levitt has decades of experience handling investigations and audits conducted by the government or third party payors, including PBMs. Regardless of the size of your pharmacy or practice, or the amount at stake, Frier Levitt is ready and able to assist you. Our experienced Life Sciences attorneys can guide your pharmacy in preparing for audits and take a strategic approach to protect your rights. If you have questions or need help fighting adverse actions, contact us to speak to an attorney.
