Pharmacy Benefit Managers (PBMs) have been using “Member Denial” discrepancy type when conducting audits against independent pharmacies. These “Member Denial” discrepancies can relate to a variety of aspects of a given claim including denials of remitting copayments, receiving their medication, and/or requesting their medication. These allegations are challenging to overcome and put pharmacies in a difficult position.
Why Patients Deny Claims
Member Denial discrepancies typically stem from PBMs contacting the members (i.e., pharmacy patients), and asking them vague, seemingly innocent questions or try to put pressure on patients to provide incorrect answers. Patients are often questioned about prescriptions that they received months or even years in the past. Patients have difficulty remembering minute details surrounding a given claim such as the precise copay amount or whether a manufacturer coupon was used to lower the applicable copay. To illustrate, if a PBM asks a patient how much they were charged for their copay and the patient does not remember the amount paid, the PBM will take the incorrect answer as a basis to assert Member Denial discrepancies against the pharmacy. PBMs benefit from their vague line of questioning and predatory practice, as patients ordinarily do not understand the consequences of their conversation with PBMs and the impact upon the pharmacies. As such, patients may provide information they believe is insignificant for their pharmacy, but ultimately results in adverse audit findings being issued against the pharmacy.
While this is not to say members are completely unaware of their healthcare history, the questions PBMs are soliciting answers to are usually related to prescription filling, billing, and interactions that took place several months or over a year ago. As a result, details simply may be wrong or forgotten and rather validate the accounts of each member, PBMs swiftly take action against the pharmacies. Additionally, Frier Levitt attorneys have seen this practice further abused where PBMs target vulnerable patient populations such as patients receiving multiple medications or elderly patients.
Contesting Member Denial Discrepancies
After contacting members and receiving the types of answers they are searching for, PBMs utilize the information learned and allege Member Denial discrepancies in pharmacy audit findings. PBMs view these interactions with members as discrepancies once there is any indication that a member may not be clear of who prescribed the prescription, when they received or requested the prescription, and whether or how much they paid for the prescription copay. Once such discrepancies are identified by a PBM, they can be difficult to return, as PBMs often consider these strong-armed patient statements in very high regard.
Unfortunately, these ever-challenging discrepancies are often utilized as a basis for termination. Unlike other discrepancies that are more easily challenged given the availability and accuracy of supporting documentation, PBMs are aware of the challenge in contesting Member Denial discrepancies and rely upon them to justify terminations following the close of an audit. It is important for pharmacies to proactively enforce mitigation efforts and adequately appeal any Member Denial discrepancies they face to ensure protection against PBM termination efforts.
Frier Levitt attorneys are well versed in this specific PBM tactic and have successfully assisted pharmacies in compiling the necessary supporting documentation, such as patient attestations specifically recanting previous statements made during adversarial or leading lines of questioning to reverse any false allegations in PBM audit findings. Frier Levitt attorneys combine their expertise in the field with tools such as the pharmacy’s contractual appeal and dispute resolution rights afforded by PBM Provider Manuals. Likewise, our attorneys have guided pharmacies in minimizing the risk of experiencing Member Denials through implementation of robust policies and procedures including increased diligence related to a pharmacy’s record keeping practices.
How Frier Levitt Can Help
If your pharmacy is facing a PBM audit or audit findings, please contact Frier Levitt to speak to an attorney today. Our life sciences attorneys are prepared to provide guidance as your pharmacy prepares for audits as well as take an aggressive approach to fight for your rights following a PBM audit. If you have questions or need help fighting adverse PBM actions, contact us to speak to an attorney.
