PBM Audits On Prescription Claims Submitted During COVID-19

In the recent months, Frier Levitt has noticed a significant spike in the number of audits conducted by Pharmacy Benefit Managers (“PBMs”) on prescription claims submitted by the pharmacies during the novel coronavirus (“COVID-19”) pandemic.  During these audits, PBMs request a number of documents from the pharmacies when, in fact, PBMs and other governing bodies such as Boards of Pharmacy issued certain waivers to ensure that patients have uninterrupted access to medications during the pandemic.  More troubling, PBMs often reject, without providing any details, documents submitted by the pharmacies for failing to meet their audit guidelines.  As such, it is critical that the pharmacies are cognizant of this recent audit trend and challenge, by utilizing legal tools available to them, negative audit findings.  

More specifically, one of the main discrepancies found in PBM audits involving prescription claims submitted during the pandemic is signature log/proof of delivery.  Due to the pandemic, the pharmacies were often unable to obtain signature logs.  Indeed, many PBMs and State Boards of Pharmacy had issued waivers allowing the pharmacies to maintain contemporaneous records (e.g., writing “COVID-19” on the signature box or confirm delivery through phone call, text, or email) in lieu of a patient signature.  However, even when the pharmacies submitted contemporaneous records demonstrating delivery of the prescriptions, PBMs decline to accept the documents and impose negative audit findings upon the pharmacies.  The pharmacies are then tasked with challenging the audit findings and the associated recoupment, which will likely interfere with their day-to-day operation as well as patient care.  Therefore, it is wise for the pharmacies to prepare and submit ample records that meet or satisfy PBMs’ audit guidelines, and fully challenge negative audit findings by utilizing legal tools available to the pharmacies including, without limitation, State Fair Audit laws. 

How Frier Levitt Can Help

It is imperative that pharmacies are aware of their rights and responsibilities when combating PBM audits.  If your pharmacy is facing an audit and/or recoupment from PBMs, contact us today to speak to an attorney.  Our Life Sciences team has the tools and experience to assist pharmacies in their audit disputes and to advise clients on proactive measures to prevent audit recoveries and network interruption.