ESI Recoupment Letters: Absence of Prescriber-Patient Relationship

At the request of the Defense Health Agency (“DHA”), Express Scripts, Inc. (“ESI”) has begun sending letters to some of the pharmacies within its network recouping on claims that had been submitted to TRICARE. This recent batch of letters is particularly notable because they focus on the results of DHA investigations – as distinct from an audit – a particularly powerful tool that enables ESI to evaluate and review claims submitted up to five years ago. In the vast majority of instances, the discrepant claims identified related to claims submitted for compounded drugs. Though ESI’s letters reference a host of potential reasons for the recoupments, ESI’s chief concern appears to be based in allegations that medications were dispensed to patients in instances in which the requisite prescriber-patient relationship did not exist.

What constitutes a valid prescriber-patient relationship often varies from state to state, and is very heavily dependent on the fact.  Several factors can be viewed as “red flags” when assessing doctor-patient relationship, including the location of the patient relevant to his or her prescriber, or that the prescriber did not submit claims for a patient visit on or around the time the prescription was written.

While these recent letters are recoupment actions, if ESI makes a determination that a patient-prescriber relationship is lacking, ESI may also proceed to terminate the pharmacy from its network. Moreover, because ESI’s investigation seems to pertain to claims submitted to TRICARE, a federal payor, pharmacies must also be mindful of the potential for False Claims Act exposure. As a result, it is of utmost important that these findings are appealed in a timely manner.

How Frier Levitt Can Help

Frier Levitt understands that fire does not always follow smoke – just because ESI has identified an anomaly does not necessitate the conclusion that a claim is discrepant. If you have received a letter for recoupment from ESI which mentions the absence of a patient-prescriber relationship, let us fight for you. Contact Frier Levitt today.

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