A number of Pharmacy Benefits Managers (PBMs) have been increasing its focus on a pharmacy’s collection of copayments from patients during its audits.
The routine waiver of a patient’s copayment is generally prohibited by PBMs’ manuals, and in recent months, there has been an uptick of PBMs carrying out targeted audits of pharmacies’ copayment collection and their ability to document the receipt of copayments in full. In light of these audits, it is imperative that pharmacies are prepared to demonstrate the method of their actual receipt of copayment whether it is via cash, check, credit card or otherwise. Below are a few of the onerous documentation requirements that some of the major PBMs have placed on pharmacies when copay discrepancies have been noted in the audit results:
- copies of point-of-sale register receipts
- copies of the fronts and backs of the check used to pay for the copay (if paid via check)
- copies of bank statements confirming cash deposit (if paid via cash)
- patient attestations confirming the details of how and when the copay has been collected (including the last 4 digits of credit card if paid via credit card)
Additionally, in the event of any deviations from the norm, pharmacies should be able to clearly demonstrate their policies and procedures in this regard. For example, if a pharmacy has waived a copay due to financial hardship, it must be documented sufficiently and the pharmacy should be able to demonstrate its Financial Hardship policies and procedures, including a process for screening hardship applicants and collecting certain documentation/information.
As such, regardless of the amount at stake, Frier Levitt can assist your pharmacy in successfully challenging a PBM’s audit findings or network termination. In addition, Frier Levitt can draft robust policies and procedures to help protect your pharmacy and ensure compliance with the PBM manuals and State and Federal laws. If you have any questions or need help fighting a PBM audit, contact us to speak to an attorney.
