Part 3 of 4: Abusive PBM Audit Practices (Onerous Member Verification)

Frier Levitt has been on the front-line when it comes to defending and scrutinizing audits conducted by Pharmacy Benefit Managers (“PBMs”) of independent pharmacies. Throughout our challenges against PBMs, we have uncovered and reported egregious and abusive audit tactics implemented by PBMs.  More recently, we noticed another concerning audit trend where PBMs attempt to recoup the entire reimbursement on claims already paid to pharmacies alleging that the members’ addresses do not match with the addresses on their records.  This form of member address verification has not been a part of PBMs’ routine audits.  Certainly, this is a new tactic to increase revenue for PBMs at the expense of the independent pharmacies.

More specifically, PBMs are auditing prescription claims for their members (albeit the pharmacies are without knowledge that patients are current members of the PBMs) where the delivery addresses do not match with the members’ addresses on their records.  PBMs further request that the pharmacies provide documentation and patient attestations to confirm that the prescriptions were in fact delivered to their members.  Not only that, PBMs request that the Pharmacy provide proof of Pharmacy’s licenses in the states where the prescriptions were delivered.  It is highly concerning that PBMs are placing additional burden on the pharmacies to demonstrate that the members did in fact receive their prescriptions even when the pharmacies provided “signature logs” of the patients or confirmation of delivery of the prescriptions.  In many of these cases, the patients are either simply visiting from out of state on a vacation, temporarily staying with a family member, or even college students who have a second home in a different state at the college or university they are attending.  To audit and subject the independent pharmacies merely because of the unmatched addresses is an unreasonable and abusive audit practice. 

How Frier Levitt Can Help?

PBMs clawback the entire amount of reimbursement on claims that were already dispensed by pharmacies.  It is important that pharmacies know their rights when combating PBM audits.  If your pharmacy has been subjected to an audit and/or subsequent recoupment from PBMs, contact us to speak to an attorney today and to understand the pharmacy’s rights, claims, and defenses in this issue.