A major PBM has recently begun issuing notices to pharmacies stating that they have been identified as having “atypical” dispensing activities during period claim reviews. Although these notices are not related to a formal audit, the PBM still requests that the pharmacy justify the dispensing behaviors identified, which have varied depending on the pharmacy. For example, the “atypical” activity identified for one pharmacy was related to the excessive dispensing of a drug product that is not on the PBM’s formulary, requires prior authorization, and is often flagged by the PBM for having questionable clinical value. Of note, for all claims that the PBM flagged, the PBM had successfully approved the prior authorization. It has also been observed that some pharmacies who have been authorized to dispense larger days’ supply under their retail pharmacy agreements have also received these notices indicating that they were dispensing drug products at larger volumes than a normal supply, despite those pharmacies having received express permission from the PBM to be able to do so.
Such “atypical” billing activities are often the basis of an audit of a pharmacy’s practices. For example, PBMs will often conduct additional audits or place scrutiny on pharmacies that exhibit practices that are inconsistent with other pharmacies in the PBM’s networks. For example, other atypical billing practices could include dispensing medications for only a few specific therapeutic categories rather than dispensing a wide range of medications, servicing patients who reside at a significantly far distance from the pharmacy, or a sudden increase in the number of claims in total or for particular drugs.
How Frier Levitt Can Help
It is important that pharmacies conduct regular reviews of their dispensing procedures and ensure that they maintain accurate and valid prescription information to support the dispensing of any medication, particularly in the event that a PBM identifies “atypical” billing practices. Failure to do so could result in adverse PBM actions, including, but not limited to, recoupment on the claims at issue or network termination. If your pharmacy has received similar notices of atypical activity from any PBM, please contact Frier Levitt to speak with an attorney on the matter and how you should address the notices.
