Over the past several months, numerous PBMs have stepped up audits and fraud and abuse investigations related to pharmacies’ alleged participation in the prior authorization process. While pharmacies may have varying levels of involvement in the prior authorization process (as detailed in other articles), a common tactic used by pharmacies to help facilitate prior authorizations is to create an account with an electronic prior authorization (“ePA”) company, like CoverMyMeds These ePA companies help “tee up” prior authorization forms for physicians and insurance companies. Through services like CoverMyMeds, pharmacies can help input basic demographic information about prescriptions needing prior authorizations, along with some limited clinical information, and send them to prescribers for review and submission. Many times, CoverMyMeds not only integrates directly with a pharmacy’s pharmacy management software system, but also connects directly with physicians’ EMR systems. The goal is to create a seamless process to prepare and submit prior authorization requests in an efficient and effective manner.
“Send to Plan”
While certain plans that accept submissions through CoverMyMeds will require that prior authorization be submitted only direct from the prescriber by way of the prescriber’s own account, in other instances, certain plans have allowed for pharmacies to submit prior authorization requests directly to the plan through their own CoverMyMeds accounts. For the plans that require that prior authorizations be submitted only direct from the prescriber by way of the prescriber’s own account, these plans will typically place certain restrictions on a pharmacy’s ability to submit prior authorizations to those plans under its own account (i.e., a pharmacy will be physically unable to click links to submit the prior authorization to the plan, and will only be able to send it to the prescriber). However, for plans where a pharmacy is permitted to submit prior authorizations directly to the plan, the pharmacy is typically given the option, by way of a “button,” to “Send to Plan.” This effectively submits the completed prior authorization form directly to the plan. In doing so, however, the pharmacy must take steps to ensure that all information contained in the prior authorization request is accurate, and that it has properly established its credentials with CoverMyMeds (discussed below).
CoverMyMeds Profiles
As noted above, through CoverMyMeds and other ePA programs, pharmacies are often able to apply their own unique pharmacy credentials to create their own user accounts to allow them to submit prior authorization requests to prescribers or directly to various plans. In setting up the pharmacy’s account, it is important to take steps to properly designate the account as a pharmacy account, and to avoid inadvertently creating a “prescriber account.” This requires carefully examining the registration questionnaires and instructions, ensuring that all information is accurate and that the account is properly classified. Importantly, for pharmacies that have had a CoverMyMeds account for some time, it is possible that they may be registered in a catchall category, such as a “provider.” In these instances, it is possible that they are unknowingly being given additional ePA privileges beyond what a plan might otherwise allow of pharmacies. In light of ongoing prior authorization audits, it is recommended that pharmacies properly evaluate their CoverMyMeds registration status.
How Frier Levitt Can Help
Frier Levitt has worked with numerous pharmacies to successfully defend prior authorization audits, focusing on the accuracy and truthfulness of the information submitted by the pharmacy, as well as the details contained in the pharmacy’s legitimate registration profile with CoverMyMeds. In addition, Frier Levitt has worked with pharmacies to develop comprehensive policies and procedures addressing the pharmacies’ involvement in the prior authorization process. These policies and procedures address not only legal and regulatory compliance, but also payer and PBM-specific considerations.
If you are facing a prior authorization audit or are concerned about your prior authorization practices, contact Frier Levitt today.
