Recently, Frier Levitt assisted a Texas-based pharmacy in challenging a major Pharmacy Benefit Manager’s (“PBM”) audit findings and successfully reversed approximately 90% of the discrepant amount. In the audit findings, the PBM asserted multiple discrepancies including drug invoice shortages, invalid prescription transfers, invalid prescriptions and delivery of prescription medications. Under Frier Levitt’s guidance, the Pharmacy gathered supporting documentation and submitted a robust appeal response challenging the alleged discrepancies. The PBM ultimately reversed over 90% of the audit findings. Frier Levitt continues to work with the pharmacy to address and achieve a complete reversal of the remaining discrepancies.
Pharmacies must be aware of the specific types of documentation that each of their PBMs require to address adverse audit findings. Here, the Pharmacy submitted invoices from the wholesalers demonstrating that the Pharmacy did in fact maintain sufficient inventory of the products at issue, prescriber attestation confirming the quantity prescribed was appropriately dispensed and confirming the prescriptions were properly transferred. This matter further demonstrates the importance of combating all PBM audit findings, as PBMs assert unnecessary discrepancies to use pharmacy 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 pharmacies from their network, so it is crucial for pharmacies to appeal PBM audit findings and attempt to reduce the amounts at issue to the fullest extent possible. Thus, 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 payors, including PBMs. Regardless of the size of your pharmacy 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 an aggressive approach to protect your rights. If you have questions or need help fighting adverse actions, contact us to speak to an attorney.
