Recently, Frier Levitt assisted a Texas-based pharmacy client in challenging a major Pharmacy Benefit Manager’s (“PBM”) audit findings and successfully reversed approximately 90% of the amount at issue. In the audit findings, the PBM asserted multiple discrepancies in drug invoice shortages, alleged that the pharmacy failed to collect copayment, and failed to provide sufficient evidence of patient-prescriber relationship to support its billed claims. Under Frier Levitt’s guidance, the pharmacy gathered significant supporting documentation to disprove the overwhelming majority of the PBM’s allegations, leading to the PBM reversing over 90% of the discrepancies when it issued the final audit findings. Frier Levitt continues to work with the pharmacy to address the remaining discrepancies and achieve a favorable resolution.
Pharmacies must be aware of the specific types of documentation that each of their PBMs require to address adverse audit findings. Here, the Pharmacy submitted invoices from the wholesalers demonstrating that the Pharmacy did in fact maintain sufficient inventory of the products at issue, prescriber attestation in which the prescriber explicitly confirms that the prescription was medically necessary and resulted from a valid patient/prescriber relationship, bank statements showing cash deposits, patient attestations, and monthly invoices/statements issued to patients to prove the pharmacy actually collected cash copays. In addition, the Pharmacy submitted e-vouchers that were applied to several claims which in turn eliminated the patient pay amount. Therefore, pharmacies who are contracted with the PBM must ensure they frequently maintain proper documentation of monthly statements issued to patients, cash collected to satisfy copayments, and maintain documentation that ties the cash deposit to the relevant claims.
This matter further demonstrates the importance of combating all and any PBM audit findings, as PBMs assert unnecessary discrepancies to use pharmacy audits as a source of revenue rather than ensuring compliance with applicable laws and contractual obligations. PBMs will use multiple adverse audit findings to justify terminating pharmacies from their network, so it is crucial for pharmacies to appeal PBM audit findings and attempt to reduce the amounts at issue to the fullest extent possible. Thus, seemingly “insignificant” amounts should be appealed to avoid additional future adverse actions by PBMs.
How Frier Levitt Can Help
Frier Levitt has decades of experience handling investigations or audits conducted by the government or payors including PBMs. Regardless of the size of your pharmacy or the amount at stake, Frier Levitt is ready and able to assist you. Our experienced life sciences attorneys can guide your pharmacy in preparing for audits and take an aggressive approach to protect your rights. If you have questions or need help fighting adverse actions, contact us to speak to an attorney.
