As PBMs regularly review claims submitted by pharmacies participating in their retail networks, pharmacy providers can often find themselves at risk for claim recoupment over seemingly minor issues. Frier Levitt recently assisted a California-based retail pharmacy facing a PBM audit. The PBM alleged that the pharmacy had improperly circumvented plan limits and entered incorrect information in order to receive paid claims.
Specifically, the PBM alleged that when the pharmacy submitted a claim and received a rejection, the pharmacy changed the quantity and days’ supply, rather than obtaining a prior authorization. In doing so, the PBM argued that the pharmacy was circumventing plan design and limitations. The PBM sought to recoup thousands of dollars from the pharmacy.
Importantly, while the pharmacy could have obtained a prior authorization, the pharmacy received authorization from the prescriber to proportionally change the days’ supply and quantity in a manner consistent with what was originally prescribed. Frier Levitt worked with the pharmacy to address the alleged findings and crafted an appeal response that clarified that the pharmacy did not submit claims that deviated from the manufacturer’s recommended dose just to bypass system edits or the prior authorization process. The PBM subsequently overturned the alleged discrepancies and confirmed that the pharmacy did not circumvent plan limits just to receive a paid claim.
When submitting claims, pharmacies should follow all point-of-sale messaging to determine if a claim is adequately written or a prior authorization is required from the prescriber. Furthermore, pharmacies should not change the quantity or days’ supply of medication to get paid claims unless the pharmacy appropriately obtains express approval from the prescriber to dispense the altered quantity, or follows any other required terms under the respective PBM’s Provider Manual and/or Provider Agreement. Pharmacies should maintain an operational practice to review billed claims and conduct periodic self-audits to ensure compliance with all Federal, State, and PBM requirements.
If your pharmacy is undergoing an audit or investigation and requires assistance, contact Frier Levitt to speak to an attorney. Frier Levitt’s attorneys have substantial experience and knowledge in the specific concerns that PBMs have regarding audits/investigations and have assisted numerous pharmacies in overcoming these results.
