Frier Levitt successfully reversed network enrollment denial by a national Pharmacy Benefit Manager (“PBM”) against a Georgia-based pharmacy. The PBM conducted a desktop audit along with invoice reconciliation. While the PBM did not find any negative audit findings on prescription claims, it alleged that there were drug invoice shortages (i.e., discrepancies between the amount of drug products purchased and the amount billed to the PBM). The PBM then notified the pharmacy that it will be terminated from its entire retail pharmacy network. After working with the pharmacy to address alleged drug invoice shortages, Frier Levitt submitted a robust appeal response emphasizing that there were no inventory shortfalls. Subsequently, the PBM rescinded the purported network termination without causing any interruption in the pharmacy’s services.
PBMs perform routine audits on pharmacies which many times result in a number of discrepancy findings. If the pharmacy is unable to successfully contest these discrepancy findings, the PBM may present a notice of termination. In response to this notice of termination, PBMs provide for a window of time to appeal the grounds for its termination decision. This critical time for appeal can determine the future for a pharmacy, especially, since terminations generally result in a 1-year, or even a 5-year, waiting period before the pharmacy can re-apply to the PBM network. Termination from a PBM network can cause substantial economic and reputational damage to a pharmacy. Therefore, it is vital to understand your rights as a pharmacy to appeal a termination decision.
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.
