Importance of Updating Credentialing Information with PBMs

Pharmacies often undergo changes to their businesses and operations, primarily to adapt to the changing landscape of providing pharmacy services. These changes are the natural evolution of a business over time.  However, in undergoing these changes, pharmacies should be mindful of their ongoing obligations to provide regular updates to its contracted payors.  Specifically, at the time of credentialing into a PBM network, pharmacies will provide the PBM the most current and accurate information about their business, such as, ownership information, pharmacy staff, drug mix, mailing percentages, or even something simple as contact information or business hours. The PBM will in turn utilize this information to review the pharmacy and make the decision of whether or not to admit the pharmacy. That being said, once successfully credentialed, pharmacies often overlook most PBMs’ contractual obligations to report any changes to the information provided at the time of credentialed. As a result, when PBMs review a particular pharmacy and identify any disparities between the pharmacy’s current operations and the operations reported at the time of credentialing, the pharmacy may face further action, such as being issued a notice of breach or even a notice of termination. The same requirement to update credentialing applications also applies to pharmacies that are not yet in the PBM’s network and are awaiting admission.

Frier Levitt recently assisted a pharmacy who was facing a PBM credentialing denial over the alleged failure to provide inaccurate or missing information on its credentialing application. Specifically, the PBM denied the pharmacy for not providing updated employee information. With the assistance of Frier Levitt, the pharmacy was able to resolve the denial and gained admission into the PBM’s network.

How Frier Levitt Can Help

If your pharmacy is in the process of credentialing into a PBM network or if your pharmacy has undergone any changes, however minor, since its inception and admission into PBM networks, contact us to speak to an attorney today.

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