PHARMACY ALERT: DIR Fee Performance Report Disputes Due Soon

Pharmacies and dispensing physicians should be on the alert for performance reports issued by certain PBMs with regard to prescription adherence or patient satisfaction surveys for providers participating in Medicare performance networks.  Providers will soon be receiving initial results of their Net Promoter Score (“NPS”) or other performance benchmarks for calendar year 2019. Often, PBMs will allow pharmacies a brief period—as little as 60 days—to dispute those performance reports used to justify Direct and Indirect Remuneration Fees, pharmacy price concessions, or other post point of sale fees (“DIR Fees”). Now is the time to act to fight back against these unfair DIR Fees.

One such performance metrics is the NPS used as a metric for performance. Frier Levitt recently reported on the use of the NPS in setting benchmarks for PBMs’ DIR Fee programs.  Pharmacies have a strong argument that utilization of NPS in DIR Fee calculations is unreasonable, often in violation of the federal law and subject to manipulation and abuse by PBMs.  With regard to other performance metrics, many PBMs do not provide sufficient data to prove adherence scores measured by the PBM are in fact accurate.  However, federal law is on your side. 

The Federal Any Willing Provider law requires Part D plan sponsors and their PBMs to have “a standard contract with reasonable and relevant terms and conditions of participation whereby any willing pharmacy may access the standard contract and participate as a network pharmacy.” 42 C.F.R. §423.505(b)(18). The use of NPS and other inaccurate performance data is neither reasonable nor relevant. These performance reports and related DIR Fees are ripe for challenge made by a pharmacy.  We are here to help.

How Frier Levitt Can Help

If your pharmacy’s DIR fees are subject to an NPS score or other performance metric, you may have only a short time to dispute them. If you would like to file a dispute, or simply learn more about your PBM contracts that utilize NPS or other performance metrics to calculate DIR fees and total reimbursement rates, contact Frier Levitt to speak with an attorney.