Recent PBM Audits Highlight Discrepancies with Ancillary Drug Products and the Importance of Obtaining Medical Records

As Pharmacy Benefit Managers (PBMs) review their retail pharmacy networks and conduct audits, pharmacies find themselves at risk for claim recoupment and audit discrepancies over dispensing ancillary drug products to patients when they did not fill the initial or primary prescription. Recently, we have seen a PBM allege discrepancies where the audited pharmacy dispensed alcohol prep pads, which are used to prepare the skin before the injection of insulin, to a patient without dispensing the patient’s insulin. However, and critically, the pharmacy only received a prescription for alcohol prep pads and not insulin and was nevertheless requested to provide medical records to support its dispensing of alcohol prep pads to the PBM. According to the PBM, there was no record of insulin being prescribed for, dispensed to, or paid by the member, and as such, the claims for alcohol prep pads were invalid.

The PBM’s practice of taking issue with the audited pharmacy’s dispensing of alcohol prep pads is especially troubling. Most diabetic patients utilize more than one pharmacy to fill their prescriptions for various reasons, including ease of accessibility. Moreover, with the spiraling cost of insulin (including high out-of-pocket expenses), many patients are turning to free drug programs under which insulin may not be billed to PBMs. While the patients did not fill their insulin at the audited pharmacy, the pharmacy could not confirm that the patients filled their insulin at another pharmacy or by other means. According to the PBM, because the pharmacy did not dispense insulin to the patient, the pharmacy should not have dispensed alcohol prep pads to the patient. Typically, pharmacies do not have requirements where the pharmacy must also fill the insulin prescription to dispense the prescription alcohol pads.

Of note, pharmacies have limited oversight of what prescribers decide to prescribe for their patients. Moreover, it is not in the Pharmacy’s practice to question valid prescriptions written by reputable prescribers. The prescriber is best positioned to evaluate the patients’ medical history and write prescriptions accordingly. That said, pharmacies should review all prescriptions before dispensing to ensure that the prescriptions are facially valid, written by reputable prescribers, under a valid electronic prescription authorized by the prescriber, and ensure a valid prescriber-patient relationship exists.

We urge all pharmacies to engage in accurate prescription verification practices and reasonably expect to obtain and maintain medical records from the prescribers to support all prescriptions, even though pharmacies are not required to maintain medical records. Critically, pharmacies should ensure compliance with all Federal, State, and PBM requirements and should be apprised of any critical updates or amendments to such conditions that may affect their processes and dispensing of any particular drug product.

If your pharmacy is undergoing an audit or investigation and requires assistance, contact Frier Levitt today to speak to an attorney. Frier Levitt’s attorneys have substantial experience and knowledge in the specific concerns that PBMs have regarding audits and investigations and have assisted numerous pharmacies in overcoming any subsequent results.