With the help of Frier Levitt, an independent pharmacy in Pennsylvania was able to successfully prevent a major PBM from recouping amounts for claims that were rightfully owed. Prior to Frier Levitt’s intervention, the PBM sought to claw back the amounts already reimbursed to the pharmacy, citing the pharmacy’s failure to provide the documentation requested to resolve the discrepancies alleged. Specifically, the PBM continued to allege that the pharmacy failed to provide sufficient evidence to demonstrate that the prescriptions billed to the PBM were received by its members. Despite the fact that the pharmacy had submitted signature logs obtained from the relevant members upon dispensing, the PBM refused to amend the discrepancies, because the signature logs did not include tracking information to confirm the successful delivery of the medications at issue. However, Frier Levitt attorneys quickly intervened by communicating directly with the PBM’s counsel to clarify that while the pharmacy’s method of delivery made compliance with its request impossible, the signature logs themselves demonstrated its members’ receipt of their medications. As a result of Frier Levitt’s advocacy, the PBM agreed to resolve the findings in their entirety.
This case is a perfect example of the arbitrariness of PBMs’ terms, and how they often fail to fulfil their intended purpose. PBMs often use concerns of potential fraud, waste and abuse to justify the unreasonably strict conditions placed on providers. For example, PBMs frequently require that pharmacies maintain certain documentation related to the dispensing of prescriptions billed. Similarly, PBMs require that documentation contain certain elements to confirm the validity and authenticity of such records. In theory, a pharmacy’s failure to maintain prescription documentation in accordance with PBM requirements would necessarily mean that a prescription was not actually dispensed. In practice however, a pharmacy’s inability to comply with such requirements is the result of the unreasonableness of the conditions themselves, rather than any wrongdoing. As was the case here, whether or not the pharmacy had actually delivered the relevant prescriptions to its patients was not at issue, nor was the authenticity of the signature logs previously submitted. Instead, the PBM’s refusal to amend the discrepancies rested solely on the fact that the pharmacy’s documentation did not contain the tracking information requested. A minor technicality, but ultimately the kind of non-compliance that PBMs are all too willing to use in order to justify recoupment of otherwise valid claims. Therefore, pharmacies should be just as willing to exhaust all procedures available under their provider agreement when appealing audit findings.
How Frier Levitt Can Help
If your pharmacy is currently undergoing an audit or has recently received preliminary or final audit findings from a PBM, Frier Levitt can help. Contact us today to speak with an attorney.
