The ongoing trend of increased audits surrounding invalid prior authorizations (“PAs”) has continuously remained steady throughout 2024 amongst several Pharmacy Benefit Managers (“PBMs”). Many high-cost prescriptions require a PA before being covered under a plan as a way to reduce unnecessary drug spending in favor of lower cost drug alternatives.
In addition, PBMs have varying restrictions on the level of involvement that a pharmacy may have in the PA process. Therefore, pharmacies should be cognizant of the specific PA process limitations that each individual PBM imposes on pharmacies. If not, they may be at risk of full recovery for any claims not appropriately submitted to the plan/PBM in addition to risks of being terminated from the network. PA requests should be submitted according to the PBM’s Provider Manual and/or Agreement. Hence, pharmacies participating in the PA process should review each PBMs’ policies and procedures to comply with applicable Federal and State laws, as well as the Provider Manuals and Agreements of their respective PBMs, to ensure appropriate submission of requests.
Furthermore, it is crucial to ensure that not only are PA requests being submitted appropriately, but that they are also submitted with accuracy regarding the patient’s clinical information based on supporting medical documentation. Importantly, any false, misleading, or inaccurate information submitted in the PA can lead to adverse consequences such as criminal or civil penalties, especially for the pharmacy when it has falsely submitted the information.
How Frier Levitt Can Help
Frier Levitt has the knowledge and experience to help review and analyze pharmacy practices and prior authorization processes to ensure regulatory compliance and compliance with PBMs’ terms and conditions. In addition, Frier Levitt offers flat fee services aimed at pharmacies to help prepare policies and procedures regarding the prior authorization process, and “legal audit” services that comprehensively evaluate a pharmacy’s practices. Contact us to speak to an attorney.
