Frier Levitt recently assisted Texas-based independent pharmacy that was facing a Fraud, Waste, and Abuse audit conducted by a major Pharmacy Benefit Manager (“PBM”) and successfully reduced the audit chargeback from over $1.3M to $190K. The PBM alleged the following discrepancies: (i) inadequate inventory to support claims billed; (ii) prescriptions written by unlicensed prescriber; and (iii) patients denied requesting prescriptions to be filled at the Pharmacy. Notably concerning, the PBM issued a series of discrepancy evaluation reports throughout the audit and until it issued the final discrepancy evaluation report that resulted in significant audit fines. Under the Firm’s guidance, the Pharmacy gathered the requisite documentation and our attorneys submitted the appeals to the PBM on the Pharmacy’s behalf.
Pharmacies should emphatically contest audit discrepancies and demand transparency from PBMs especially when the pharmacy provided sufficient documentation to overturn the discrepancies. Often, many pharmacies allow PBM audit findings to go uncontested due to smaller claw back amounts. Even if a PBM audit does not result in adverse action beyond the recoupment of monies from the pharmacy, PBMs keep track of their network pharmacies’ audit histories. Increasingly, PBMs are using prior audit results as justification to terminate the pharmacy years later after the pharmacy has another adverse audit finding. Though the smaller amounts may not seem “worth” disputing, failure to do so may serve as the basis for network termination by a PBM somewhere down the road.
How Frier Levitt Can Help
Regardless of the size of your pharmacy or the amount at stake, Frier Levitt is ready to assist you in successfully challenging the audit. Our attorneys include clinicians who are prepared to take an aggressive approach to fight for your rights following a PBM audit. If you have questions or need help with a PBM audit, contact Frier Levitt today to speak to an attorney.