Frier Levitt recently assisted a California-based independent pharmacy that faced an audit from a major pharmacy benefit manager (“PBM”) by successfully challenging the audit findings and reversing 100% of the purported discrepancies. During the audit, the PBM asserted various unsubstantiated discrepancies, including, but not limited to, allegations that the pharmacy’s patients denied receiving their medications. Under Frier Levitt’s guidance, the pharmacy gathered the requisite documentation, and our attorneys submitted an appeal response to the PBM on behalf of the pharmacy. The PBM then reversed all alleged discrepancies.
PBMs often attempt to use routine audits as a tool to seek unwarranted recoupment of funds from their contracted pharmacies. As discussed in our recent article, PBMs tend to impose stringent terms dictating which documents will be deemed sufficient to overturn alleged discrepancies. Thus, it is imperative that pharmacies have robust procedures to ensure they are properly retaining the appropriate documents to defeat unfounded PBM audits.
In addition, pharmacies should utilize the contractual appeal process outlined in their agreements and PBM Manuals to combat any and all audit findings, regardless of the attempted clawback amount. Oftentimes, pharmacies allow audit findings to go uncontested due to seemingly insignificant amounts at issue. Critically, 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. PBMs rely on prior audit results to justify termination of the pharmacy if the pharmacy has another adverse audit finding years later. Though these smaller audit amounts may not seem to be “worth” disputing, failure to do so may serve as the basis for severe PBM sanctions, including network termination, in the future.
How Frier Levitt Can Help
Regardless of the size of your pharmacy or the amount at stake, Frier Levitt is ready and able to assist you in successfully challenging a PBM’s audit of your pharmacy. Our life science attorneys are prepared to provide guidance as your pharmacy prepares for PBM audits as well as provide an aggressive approach to fight for your rights following a PBM audit. If you have any questions or need help fighting a PBM audit, contact us to speak to an attorney.
