Pharmacy Benefit Managers (PBMs) routinely request pharmacies to submit credentialing when seeking admission into their networks, and require re-credentialing applications to be submitted two to three years after the pharmacies’ admission. The credentialing process is quite tedious and often requires the pharmacy to answer a series of questions, and to provide underlying information and documentation. Some PBMs – OptumRx in particular – may also require that pharmacies undergo “enhanced credentialing,” which includes a further review of the pharmacies’ records, as well as often, a drug reconciliation of drugs purchased versus drugs dispensed. Drug reconciliations can be a significant endeavor for an independent pharmacy to undergo, requiring the pharmacy to reach out to all of its wholesalers, distributors, and suppliers to submit purchase information for a particular time period, while also providing corresponding dispensing data. An inadequate or incomplete response can quickly escalate to the PBM denying the pharmacy admission into the network. Specifically, if OptumRx determines that the pharmacy had any inventory shortfalls or even billing issues (i.e. submission of incorrect NDCs, regardless of whether the claims were submitted to insurance companies or dispensed to cash paying patients), OptumRx will likely allege discrepancies in the drug reconciliation, and subsequently deny the pharmacy credentialing into the network. When providing purchase information, pharmacies should ensure they are requesting all of their wholesalers, past and present, for the relevant purchase information. Further, when providing dispensing information, pharmacies should be sure to provide accurate dispensing information, exclusive of any reversed claims or claims not dispensed on, as incomplete information may lead to a denial.
If pharmacies are denied over such reconciliation issues, it is increasingly difficult to appeal the credentialing denial. Some PBMs may not even provide an opportunity to the denied pharmacy to resolve any alleged inventory shortages. In the event that the pharmacy is provided such opportunity, it is important to identify the potential basis of the inventory shortage and provide substantive information and documentation. Further, once in the network, pharmacies have a continued obligation to ensure they maintain sufficient quantities of drug product at all times.
How Frier Levitt Can Help
If you are experiencing drug reconciliation following denial of a credentialing application and need assistance, please contact us today. We have a team of attorneys focusing on PBM matters that can help cure the shortfalls, appeal the decision, and prevent future admission denials.
