Recently, Frier Levitt assisted a Texas-based pharmacy client in challenging a major Pharmacy Benefit Manager’s (“PBM”) audit findings and successfully reversed approximately 99% of the discrepancies at issue. In the audit findings, the PBM asserted multiple discrepancies related to drug invoice shortages, allegations of members denying requesting/ordering medications from the pharmacy, and discrepancies related to patients allegedly denying paying the copayments. 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 99% of the discrepancies when it issued the final audit findings, and returning thousands of dollars to the pharmacy. 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, patient attestations confirming that the patients requested the medications, and patient attestations confirming the patients made the relevant copayments. This highlights the importance for pharmacies contracted with PBMs to maintain proper documentation that they received all required patient authorization prior to filling and dispensing the prescriptions. In addition, pharmacies must maintain detailed invoices from all suppliers – including wholesalers and drug manufacturers – to support claims billed to each PBM. Finally, pharmacies must maintain documentation of collection and receipt of copayments from patients at the point of sale, in line with the documentation requirements for each PBM.
Perhaps most critical, this audit demonstrates the importance of actively seeking clarification and confirmation from patients, even when PBMs have allegedly obtained statements from members denying requesting/receiving prescriptions, or denying having paid the copayments. Being able to present patients with clear documentary evidence of having received prescription medications, and having paid the associated copayments, can be helpful in obtaining attestations form patients to combating PBM audit findings. PBMs routinely assert overly aggressive discrepancies not necessarily based on supported facts in efforts 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.
