Many pharmacies are faced with PBM audits resulting in final audit finding recoupments which can range from very large to very small dollar amounts. Many times, when the recoupment is smaller in sum, pharmacies may be inclined to forgo contesting the audit findings and simply allow the PBM to recoup the entire amount of reimbursement on claims that were already dispensed by pharmacies. The pharmacies make the economic determination that the resources expended to further contest the audit will outweigh the amounts they could get back in reversing the discrepancies.
However, it is imperative that pharmacies consider the entire economic value of challenging and opposing audit findings, beyond merely just the recoupment amount at issue. For example, there has been an increasing trend of pharmacies being terminated from pharmacy networks by PBMs due to a pharmacy’s affiliation and/or common ownership with providers who have been previously terminated from the PBM’s pharmacy network for even relatively insignificant audit recoupments. Many times, this results in the affiliated pharmacy having to attempt to challenge audit findings that were rendered long ago, and may have been much easier to defend at the time.
Responding to audits can certainly disrupt a pharmacy’s day-to-day business. However, pharmacies should vehemently contest audit discrepancies, especially when the pharmacy has provided sufficient documentation to overturn the discrepancies as PBMs maintain records of each pharmacy’s audit history. Smaller amounts of recoupments from audit findings may seem as “worth” disputing, however, the failure to do so can provide a PBM with basis for network termination.
How Frier Levitt Can Help
Irrespective of the size of your pharmacy or the amount at stake, it is imperative that a pharmacy challenges any audit findings it has, to help combat further action by the PBM. If your pharmacy is facing a PBM audit or PBM network termination contact Frier Levitt today to speak to an attorney.
