Frier Levitt recently represented three medical practices faced with significant overpayment demands. Insurance companies have been auditing practices at a feverish pace that has only increased over the past few years. When audit "failures" can be based on simple documentation errors, an oversight in credentialing, or a multitude of other arbitrary reasons, overpayment demands are a near certainty.  Due to payors' use of extrapolation, audits are leading to very large...

Recent enforcement actions over allegations regarding assisting pharmaceutical manufacturers to pay improper kickbacks to Medicare beneficiaries are not the only issues currently impacting Patient Assistance Programs (PAPs). PBMs are also taking an increasingly hard stance over the use of PAPs by specialty and retail pharmacies across the country. Some PBM Provider Manuals include explicit terms and conditions regarding the use of financial hardship policies, but many are silent with regard...

Virginia-based Sentara Hospitals has agreed to a $2.175 million settlement with the Office for Civil Rights at the U.S. Department of Health and Human Services (OCR) for alleged violations of the Health Insurance Portability and Accountability Act (HIPAA) on behalf of its ten hospitals. On April 17, 2017, the OCR received a complaint alleging that an incorrect hospital bill, containing another patient's Protected Health Information (PHI), was mailed to a...

As the calendar year comes to an end, Pharmacy Benefit Managers (PBMs) often review pharmacies that participate in their networks. Such reviews may include an evaluation of past audit performances or any past adverse action taken against the pharmacy, or such reviews might include requesting the pharmacy to undergo "re-credentialing." Pharmacies that are asked to undergo re-credentialing are often asked a series of questions associated with general ownership structure, location...

In September 2018, New Jersey Governor Phil Murphy announced that the State of New Jersey awarded the Pharmacy Benefit Manager (PBM) contract to OptumRx and agreed to pay OptumRx $6.7 billion over three years to manage and administer pharmacy benefits for the State. Although "reverse auction" is a step in the right direction, such procedure is meaningless unless Plan Sponsors implement contractual tools that protect themselves from PBMs' revenue tactics...