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PHARMACY ALERT: PBM’s Recouping on Telehealth Prescriptions

Pharmacy Benefit Managers (PBMs) regularly audit independently-owned pharmacies and seek recoupments on allegedly discrepant claims for a number of different bases. Recently, Frier Levitt has seen an uptick in the number of audits whereby PBMs have decided to recoup claims based on allegedly “invalid prescriber-patient relationships.” Specifically, PBMs are claiming that the underlying prescriptions are discrepant because of “invalid” telemedicine encounters between the patients and their respective prescribers, creating an “invalid relationship” and allowing the PBM to seek recoupment. This has come in a few different forms, with some PBMs stating “Patient denied valid doctor-patient relationship” or “Physician denied validity of the prescription.”

Pharmacies that encounter such discrepancies are faced with the difficult task of assessing the various state-specific telehealth regulations associated with the prescriptions at issue in order to otherwise refute the PBM’s allegations that there was an invalid patient-prescriber relationship. In addition, PBMs have also been subjecting pharmacies who receive transferred prescriptions associated with telemedicine encounters to recovery on the alleged basis that there was not a valid patient-prescriber relationship associated with the transferred prescriptions. This makes it especially difficult given the legal requirement for closing pharmacies to transfer their prescriptions to another licensed pharmacy.

How Frier Levitt Can Help
If your pharmacy is currently facing a PBM audit and those prescriptions are based on telemedicine encounters between patients and physicians or if your pharmacy is processing prescriptions associated with telemedicine encounters, contact Frier Levitt today to speak to an attorney. Our Life Sciences team has the tools and experience to assist Pharmacies in their audit disputes and to advise clients on proactive measures to prevent audit recoveries.