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 After submitting an appeal addressing the “Prescriber Denial” discrepancies as well as prompt pay laws, the PBM rescinded the entire discrepancies and reduced the audit chargeback from $150K to $0.
“Prescriber Denial” is a common discrepancy type raised in a routine audit and one that is often abused by PBMs. For example, we have seen instances where PBMs use “Prescriber Denial” discrepancies on claims when the prescribers did not return the PBM’s inquiries. Nonetheless, the pharmacies are then tasked with presenting evidence demonstrating that the prescriptions were written or authorized by the prescribers. Importantly, failing to appeal negative audit findings will likely have devastating impact upon a pharmacy’s day-to-day operation as well as patient care. Any discrepancies or overpayments identified in a PBM audit that are not successfully appealed will result in the recoupment of reimbursements on claims that were already dispensed by the pharmacy or withholding of funds from future remittances owed to the pharmacy.
How Frier Levitt Can Help
If your pharmacy is currently facing a PBM audit, contact Frier Levitt today to speak to an attorney. Our Life Sciences team has the tools and experience to assist Pharmacies in their audit disputes and to advise clients on proactive measures to prevent audit recoveries.