Pharmacy Benefit Managers, or PBMs, regularly audit pharmacies for their prescriptions, inventories, and general practices, in order to ensure such pharmacies are maintaining compliant practices in relation to the PBM’s Provider Agreement and Manual. While audits and potential audit discrepancies may lead to enhanced terms and conditions of participation or network termination, any such issues often remain confined to the pharmacy’s relationship with the respective PBM. However, in limited instances, PBMs have previously reported findings, often those associated with suspected fraud, waste, or abuse to state and federal agencies.
However, the more alarming concern (and a growing recent trend) arises where a PBM complains or refers a pharmacy to a state or federal Agency for reasons that are more closely associated with contractual violations than any violation of state and/or federal rules and regulations that might otherwise justify a complaint. For example, recently, a PBM filed a complaint against a pharmacy with the pharmacy’s State Board of Pharmacy for reasons largely associated with contractual violations, such as relatively minor audit discrepancies based on the PBM’s own terms and conditions, mailing claims to patients under a retail contract, and alleged failures to disclose common ownership.
How Frier Levitt Can Help
In light of this recent uptick of complaints, pharmacies that undergo audits and receive audit discrepancies are highly encouraged to resolve, or at least address, such discrepancies with the respective PBM to ensure that further action does not ensue. If your pharmacy has been notified of a Board of Pharmacy complaint filed against your pharmacy, or if your pharmacy is undergoing an audit, contact Frier Levitt to speak to an attorney today.
