PBMs Continue to Scrutinize Claims Submitted During COVID-19 Pandemic

Pharmacy Benefit Managers (“PBMs”) continue to scrutinize pharmacies for prescription claims submitted during the coronavirus outbreak (“COVID-19”).  Importantly, many PBMs, payors, and governmental bodies including the Center for Medicare & Medicaid Services (“CMS”) and state Boards of Pharmacy (“BOPs”) had taken actions to ensure that patients have access to healthcare.  These included, without limitation, allowing early refills on 30-day maintenance prescription drugs, temporary suspension of audits, temporary suspension on enforcement against prescription mail delivery services for retail pharmacies, waiver of signature logs, and DAW 8 override in the event of drug shortage (collectively, “Waivers”).  However, PBMs have not only begun to scale back certain Waivers (while a number of governmental bodies extended such measures) but also have been increasing their audit activities against independent pharmacies and their claims submitted during COVID-19. 

More troubling, PBMs did not take Waivers into consideration, even the ones implemented by them, when auditing claims submitted by the pharmacy during COVID-19.  Instead, PBMs identified claims as discrepant if the claims did not meet the terms set forth in their Provider Agreement/Manual as well as other applicable Federal and state regulations.  For example, a claim would still be discrepant if the pharmacy could not provide signature log or if the claim was mailed to the patient despite the fact that the pharmacy was allowed to maintain corroborating records in lieu of signature log and to mail prescriptions to mitigate the risk of COVID-19 infection for patients and their employees.  In turn, the pharmacy is forced to gather supporting documents and try to persuade the PBM that the pharmacy filled the prescriptions in accordance with their Provider Agreement/Manual as well as Waivers.  PBMs’ inconsistent auditing standards, i.e., not considering Waivers may likely cause financial setback to the pharmacy, and hinders patient care. 

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.

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