A Utah-based pharmacy was facing a $150K recoupment following an audit conducted by a national Pharmacy Benefit Manager (“PBM”).  Upon release of the initial audit results, the PBM alleged that the prescribers for the prescriptions in question denied authorizing the prescriptions.  After submitting an appeal addressing the “Prescriber Denial” discrepancies as well as prompt pay laws, the PBM rescinded the entire discrepancies and reduced the audit chargeback from $150K to...

Frier Levitt recently assisted Texas-based independent pharmacy that was facing a Fraud, Waste, and Abuse audit conducted by a major Pharmacy Benefit Manager (“PBM”) and successfully reduced the audit chargeback from over $1.3M to $190K.  The PBM alleged the following discrepancies: (i) inadequate inventory to support claims billed; (ii) prescriptions written by unlicensed prescriber; and (iii) patients denied requesting prescriptions to be filled at the Pharmacy.  Notably concerning, the PBM...

Frier Levitt previously reported that certain Direct and Indirect Remuneration (“DIR”) fee reports would be available soon from Pharmacy Benefit Managers (“PBMs”) and last week, a major PBM distributed its report to providers. Often, PBMs will allow pharmacies a brief period—as little as 60 days—to dispute those performance reports used to justify DIR fees, pharmacy price concessions, or other post point of sale fees. PBMs implement DIR fee programs that...

On Friday, June 26, Pfizer filed a Complaint seeking a Declaratory Judgment in the Southern District of New York against the U.S. Department of Health and Human Services.  The suit alleged that the agency’s incorrect interpretation of two laws, namely the federal Anti-Kickback Statute (“AKS”) and the Beneficiary Inducement Statute (“BIS”), has prevented and continues to prevent many patients from accessing expensive medications, specifically medication manufactured by Pfizer intended to...

This week, a new phenomenon began to emerge, impacting compounding pharmacies that previously received letters dated April 7, 2020 from Express Scripts, Inc. (“ESI”) initiating recoupment actions. At the request of the Defense Health Agency (“DHA”), ESI sent letters dated June 25, 2020 to some of the pharmacies within its network suspending the recoupment actions initiated on April 7, 2020 based on the lack of a Prescriber Patient Relationship, until...