With the help of Frier Levitt attorneys, Harini Bupathi and Andrea Hageman, a Florida pharmacy was able to successfully reverse audit findings issued against it by a major PBM in their entirety, resolving any chargeback or potential adverse action related to the audit. Briefly, the audit amount originally placed at issue related exclusively to instances in which the PBM alleged that its members denied receiving or requesting the prescriptions which the pharmacy had submitted for reimbursement. Despite the Pharmacy’s compliance with the underlying audit request, the PBM alleged that the Pharmacy had not sufficiently established the validity of these prescriptions, based solely on alleged denials from its members. However, with the help of Frier Levitt, the pharmacy was able to submit written attestations from the relevant patients, in which they explicitly confirmed that they had in fact received and requested that the prescriptions be dispensed by the Pharmacy, ultimately leading to the reversal of these findings in full.
Frier Levitt has previously reported that PBMs have been relying almost entirely on the denials of their members that the PBM allegedly obtain during outreach to patients in the course of an audit or investigation over the Pharmacy’s submission of signature logs, copayment receipts, and sometimes tracking confirmations which otherwise confirm that prescriptions have been received or requested by their members. This pharmacy’s situation is yet another example of this troubling trend, further emphasizing the importance of maintaining complete and accurate records as required by the terms and conditions of their PBMs’ provider manuals. Beyond ensuring compliance with the PBMs’ manuals, pharmacies should be sure to be maintain documentation that tends to prove patient receipt, including signature logs obtained at point-of-sale, or tracking confirmations demonstrating that prescriptions were successfully delivered to the patients’ addresses. Likewise, this situation also highlights the importance of obtaining explicit authorization from patients prior to filling a prescription, as well as documenting when and how such authorization is obtained. By maintaining clear evidence that patients authorized the filling of their prescriptions, and that they received their prescriptions, pharmacies will ensure they are able to effectively disprove any PBMs’ claims to the contrary.
How Frier Levitt Can Help
If your pharmacy is currently being audited or has recently received audit findings alleging that patients have denied either receiving or requesting their medications, Frier Levitt can help. Contact us today to speak with an attorney.
