As part of routine audits, Pharmacy Benefit Managers (“PBMs”) regularly request pharmacies to produce documents pertaining to prescription claims. Amongst the documents commonly requested are copies of prescriptions, prescription labels, and signature logs signed by patients or their authorized representative such as family members when a prescription is picked up. In the recent months, Frier Levitt has noticed an alarming trend where PBMs refuse to accept signature logs signed by a patient’s authorized representative and, instead, demand additional documentation.
Signature logs demonstrate that the prescriptions were dispensed to the patients, directly or indirectly through their authorized representatives, and that the patients consented to having the pharmacy fill the prescriptions. In that vein, PBMs’ Provider Manuals frequently contain provisions that denote a patient’s authorized representative may pick up prescriptions on behalf of the patient. Additionally, these provisions indicate that the consent of a patient’s authorized representative is sufficient to prove the patient’s consent. Critically, as mentioned above, PBMs have been refusing to accept signature logs signed by a patient’s authorized representative. For example, a national PBMs requested additional documentation from an independent pharmacy demonstrating that the patient consented to having a family member pick up the prescription. More troubling, the PBM failed to indicate what additional documentation would be sufficient to establish such consent. By and through such an egregious audit practice, PBMs are placing additional burden upon the pharmacy to demonstrate that it did in fact dispense the prescriptions to the patients’ authorized representative. Otherwise, PBMs will recoup the reimbursement paid on the prescription claims (albeit the pharmacy had already dispensed the medications to the patients) and may subject the pharmacy to additional sanctions such as payment/adjudication suspension and network interruption. Therefore, pharmacies must challenge PBMs’ unconscionable audit practices and audit findings.
How Frier Levitt Can Help
It is imperative that pharmacies are aware of their rights 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.
