Auto-refill policies are a convenience-driven approach to pharmacy services, designed to ensure that patients with chronic conditions receive their medications in a timely manner. Through pharmacy software programs, pharmacies can automatically refill prescriptions for eligible patients, thus promoting medication adherence and improving patient outcomes. However, the implementation of such policies has drawn the attention of PBMs (e.g., CVS Caremark, Express Scripts, OptumRx) for several reasons.
Auto-refill policies can sometimes lead to billing complications, with PBMs arguing that they make it difficult to track and manage medication utilization effectively. PBMs may question the timing and necessity of auto-refill requests, leading to audit findings and associated recoupments. PBMs have been increasingly using audits to target pharmacies that have implemented auto-refill policies. These audits are designed to examine the pharmacy’s adherence to contractual and regulatory requirements, specifically with respect to prescription fulfillment and billing practices.
The audits can encompass various aspects including, without limitation, the following:
- Medication Adherence: PBMs scrutinize whether pharmacies are adhering to medication synchronization programs and ensuring patient consent for auto-refill services.
- Prescription Accuracy and Medical Necessity: PBMs evaluate the accuracy of prescriptions and the suitability of auto-refill policies for certain medications.
- Billing Practices: Auditors review the pharmacy’s billing practices to ensure that they align with the contractual agreement, including timely claims submissions and adherence to specific reimbursement rules.
In a recent audit conducted by a major PBM, a pharmacy client utilizing an auto-fill program faced extensive audit findings stemming from the auto-fill program and the program’s associated risks. Specifically, the PBM alleged drug invoice shortage and patient denials. With respect to the patient denials, there were allegations of patients denying both requesting the medication as well as receiving the medication. As a result of the auto-fill program, certain claims were automatically refilled regardless of whether the patient intended to receive the medication. Thus, when the claims were refilled, claims were inadvertently submitted to the PBM that were not received by patients. Consequently, it appeared that inventory shortages existed because the automated refills presented an illusion that the pharmacy dispensed far greater quantities than it purchased during the relevant timeframe. While this situation serves as only one example of the potential risks of utilizing an auto-fill program, it provides a valuable lesson about the potential unintended consequences of auto-fill programs.
There should be no dispute that pharmacies can encounter substantial challenges when they are targeted by PBMs. Audit findings can result in recoupments as well as network interruption (e.g., suspension, termination). Moreover, pharmacies are forced to prepare for and respond to PBMs’ audits and demands, which in turn, place significant administrative burden on the pharmacies, taking time and energy away from providing patient care.
In light of these challenges, it is essential for pharmacies to be well-prepared and informed when dealing with PBM audits. This includes understanding their contractual agreements, complying with applicable regulations, and having strong documentation to support their practices.
