Thanks to Frier Levitt attorneys, an Ohio pharmacy is now able to continue its participation in a major PBM’s provider network, despite the PBM’s attempt to terminate the Pharmacy from its network due to instances in which the PBM’s members were alleged to have denied requesting medications which were otherwise properly dispensed and billed to the PBM. However, with the help of Frier Levitt attorneys, the Pharmacy was able to successfully dispute the denials cited as a basis for its termination, address other areas of concern raised by the PBM, and demonstrate that the Pharmacy met the terms of its continued participation, securing its status as a network provider.
While a termination can often be triggered by “significant” audit findings, the type of discrepancies allegedly identified by the PBM may also increase the likelihood of a termination, even in instances where there is a minor dollar amount at issue or only a small number of discrepancies alleged. For example, the pharmacy’s termination in this case was triggered by a small number of members alleged to have denied authorizing the pharmacy to fill their medications. However, due to the nature of the discrepancies and the conduct at issue, member denials often trigger further disciplinary action against a pharmacy, no matter how few denials or how small the amount of recoupment is.
It is also important to note that while a notice of termination may cite specific conduct or discrepancies, pharmacies may also be required to address other concerns expressed by the PBM regarding its future participation in the network that are completely unrelated to the discrepancies which triggered the termination in the first place. For example, as was the case here, PBMs have inquired about and even made explicit requests for additional information regarding certain business practices and operational procedures when considering a pharmacy’s participation in its network. Accordingly, when appealing a termination, pharmacies should be prepared to address any and all concerns expressed by the PBM in order to successfully maintain its status as a network provider, even where such concerns may not have been cited as an express basis of termination originally.
How Frier Levitt Can Help
As we near the end of the year, many PBMs will be assessing the performance of their providers and taking steps to terminate any pharmacies which are deemed to be non-compliant with the terms and conditions of its provider agreement. If you are concerned about the potential termination of your pharmacy, or have recently been terminated by a PBM, Frier Levitt can help. Contact us today to speak to an attorney.
