AmeriHealth Caritas (AmeriHealth) is a managed care organization that commonly provides Medicaid services in many states, and manages many large Medicaid managed care plans including AmeriHealth Caritas Pennsylvania, Keystone First, Keystone First Community HealthChoices, and AmeriHealth Caritas District of Columbia, to name a few. Notably, AmeriHealth processes claims for pharmacy benefits through PerformRx’s Pharmacy Benefit Manager (PBM).
Notwithstanding its role as a plan sponsor in PerformRx’s PBM network, AmeriHealth plans routinely audit claims to ensure they are paid accurately and in compliance with applicable Federal and State regulations/laws, as well as terms set forth by AmeriHealth. However, such audits/investigations typically arise from the plan’s Special Investigations Units (SIU) with allegations of fraud, waste and abuse (FWA). That said, Frier Levitt has recently observed an uptick in AmeriHealth plan audits/investigations which appear to stem from the SIU. Importantly, a common theme we have noted in the audits/investigations have been allegations involving issues surrounding invalid prior authorizations, inventory reconciliations, and patient consent to receive medication. This is concerning for independent pharmacies as they are having to defend themselves against alleged FWA audit findings, which have often become drawn-out processes, including an initial request by AmeriHealth for various types of records, follow up requests, initial findings issued by AmeriHealth, an appeal prepared and submitted by the pharmacy with supporting evidence, and issuance of final findings by AmeriHealth. Despite complying with the audit process, we have seen AmeriHealth often take a draconian approach, issuing significant final audit findings, monetary recoupment, and/or network termination. Further, pharmacies must be aware that AmeriHealth routinely reports these audit findings to regulatory and governmental authorities, such as State Boards of Pharmacies, Medicaid Fraud Control Units, criminal prosecutors, and more.
Thus, being vigilant of the areas AmeriHealth has focused on is critical for pharmacies to properly prepare for and respond to these audits/investigations. Pharmacies should take an aggressive approach to combat any and all such audit findings to the fullest, regardless of the amount at issue to avoid further adversarial action, including but not limited to, network termination and escalation to regulatory/governmental bodies.
If your pharmacy is faced with an AmeriHealth audit/investigation, Frier Levitt is prepared to step in and engage with AmeriHealth’s counsel to strategize and further discuss the possibility of negotiations and settlements along with payment plans. Please contact Frier Levitt to speak to an attorney today.
