Thanks to Frier Levitt attorneys, Harini Bupathi and Andrea C. Hageman, a Texas pharmacy was finally able to recover approximately $680,000 wrongfully withheld by a major PBM. Despite the less than $20,000 audit findings previously issued against the pharmacy, the PBM continued to withhold payments otherwise rightfully owed to the pharmacy for services provided to its patients after the audit. Frier Levitt attorneys immediately reached out to the PBM demanding the release of these improperly withheld funds. Unbeknownst to the pharmacy, the PBM recently issued an extended audit against the pharmacy, and per the PBM, such extended audit was confirmed to be the cause of the continued withholding. Accordingly, Frier Levitt worked with the pharmacy to ensure the timely submission of the documents requested by the PBM and exhaust the audit process. However, even after the PBM had completed its audit, and issued minor discrepancies that resulted in a nominal recovery of less than $16,000 dollars, the pharmacy had yet to receive its withheld payments from the PBM. With further intervention from Frier Levitt attorneys, the pharmacy was able to ensure the release of the funds by the PBM and successfully recover the full amount directly from their pharmacy services administrative organization (PSAO).
This pharmacy’s situation highlights the importance of careful accounting, particularly following the issuance of audit findings, and to ensure that PBMs appropriately release any withheld funds. Additionally, pharmacies should make sure that their PBMs are making prompt payments on clean claims. In the event a PBM fails to make timely payment, pharmacies should work to address the issue immediately. Pharmacies should also keep in mind that while payments are commonly withheld directly by PBMs, payment can also be withheld by PSAOs. While the withholding of these payments is likely directly related to a PBM audit, sometimes a PSAO may withhold payment even without an explicit request from the PBM to do so. Therefore, pharmacies should be sure to identify whether payments are being withheld by the PBM or PSAO, so they are sure that the funds are being released by and to the proper party.
How Frier Levitt Can Help
If your pharmacy is experiencing payment withholding from its PBM or PSAO, Frier Levitt can help. Contact Frier Levitt today to speak with an attorney.
