Recently, Frier Levitt attorneys reversed 100% of audit findings for a Maryland based pharmacy following an audit conducted by a national Pharmacy Benefit Manager (“PBM”). The pharmacy faced thousands of dollars in copayment discrepancies, but under the direction of Frier Levitt’s attorneys, the pharmacy successfully overturned the discrepancies in their entirety.
Following the initial audit, the PBM identified a number of copayment discrepancies, alleging that the pharmacy failed to collect required patient pay amounts at the point of sale. This is a common discrepancy type typically identified by PBMs throughout the duration of a pharmacy audit. However, these allegations are often times overcome largely in part due to superb record keeping procedures as well as an internal review of a pharmacy’s documents.
Failure to Collect Copayment
During this audit, the PBM identified a single discrepancy type, alleging the pharmacy’s failure to collect copayment on a number of prescription claims. Frier Levitt sees and deals with this specific discrepancy type quite often. However, there are varying options as to documents suitable to combat this discrepancy type, and each case uniquely depends on the pharmacy’s record keeping practices. Through the numerous audits our attorneys have successfully managed, Frier Levitt has become well experienced in the review and assessment for which documents are best to combat a specific discrepancy type, as well as the likely acceptance of the documents by the PBM. In the case of the present matter, the pharmacy had done an excellent job at maintaining its pickup and proof of payment records. Specifically, the pharmacy maintained copies of the receipts for the claims at issue as well as credit card payment history. The two being indisputable. Fortunately, Frier Levitt, following a review of the documents, was able to determine their validity and included them in the pharmacy’s appeal response. Thus, creating a comprehensive appeal of the PBMs initial findings, addressing each of the claims at issue and providing concrete evidence of copayment collection.
Key Takeaways
This matter demonstrates the importance of stringent document management practices. Providing hard evidence of the original payment methods, as well as proof of payment, affords the pharmacy the opportunity to avoid further documentation collection that would likely be under heightened scrutiny by the PBM. Being able to provide PBMs with indisputable evidence of the pharmacy’s practices or supporting documents is an ideal way to overturn adverse audit findings. Moreover, organized management practices enable a pharmacy to provide supporting evidence in a timely manner, avoiding the risk of missing strict appeal deadlines.
How Frier Levitt Can Help
At Frier Levitt, we are committed to supporting independent pharmacies in navigating these complex challenges posed by PBMs. Our team of seasoned attorneys is dedicated to defending pharmacies against unjust PBM practices and ensuring their continued ability to serve their communities. If your pharmacy is facing audit threats or other PBM-related issues, we are here to help you protect your business and secure your future. Please contact us today to speak to an attorney. By staying informed, prepared, and united, independent pharmacies can resist the pressures of PBM audits and network terminations, ensuring their vital role in the healthcare system.
