Pharmacy Alert: Routine PBM Audits Request Extensive Policies and Procedures

In a recent trend, several PBMs have been requesting additional documentation during the time of a routine audit of pharmacies.  Specifically, PBMs have been requesting several policies and procedures related to a variety of a pharmacy’s practices, particularly when conducting a desktop audit of the pharmacy. For example, during an audit, PBMs will request significant prescription documentation for a number of identified claims, and such documentation will generally include a copy of the original prescription, proof of delivery, a copy of the drug label, and proof of copayment collection, to the extent applicable.  However, in addition to this routine documentation, some PBMs have also requested that pharmacies provide a copy of their policy and procedure of copayment collection.

When submitting any policy and procedure, including on the issue of copayment collection, pharmacies should be conscious to ensure that their written policies are consistent with not only applicable rules and regulations, but importantly, are also consistent with the PBM’s terms and conditions in order to avoid any further scrutiny. Further, pharmacies should also ensure that they are actually adhering to any policy and procedure they have implemented in their pharmacy which are being submitted to the PBM, particularly where the written policy is another means of measurement to identify a pharmacy’s compliance. While PBMs have recently been requesting policies on copayment-collection practices, the request could easily extend to other areas of pharmacy practices, such as inventory management, validation of prescriptions, etc.  Therefore, it is increasingly important in light of this audit trend that pharmacies have robust policies and procedures that are strictly observed. Furthermore, pharmacies that seek reapplication into a PBM network following a termination are also encouraged, if not required, to maintain and follow comprehensive policies and procedures, particularly those that address the underlying basis of the PBM’s decision to terminate the pharmacy.

How Frier Levitt Can Help

If your pharmacy is undergoing an audit and is being requested to provide policies and procedure, or if your pharmacy does not have any such policies and procedures and would like to be proactive in ensuring compliance with applicable rules and regulations and PBM requirements, contact Frier Levitt to speak to an attorney today.