Frier Levitt is Successful in Reversing Readmission Denial

Frier Levitt successfully reversed a five year wait for readmission for an independent pharmacy into one of the largest Pharmacy Benefit Managers (“PBM”) pharmacy networks.  More specifically, the pharmacy was terminated by the PBM in 2017 for failing to provide invoices and purchase summaries to demonstrate that the pharmacy had sufficient inventory of certain medications compared to the total amount of billed claims.  Frier Levitt assisted the pharmacy in implementing a Corrective Action Plan as well as other practical measures, which allowed the pharmacy to re-apply for admission into the provider network, instead of waiting five years. 

Importantly, PBMs continue to closely monitor independent pharmacies and their claims submission.  As part of the monitoring, PBMs conduct audits and Fraud, Waste and Abuse (“FWA”) investigations on a regular basis.  Following such audits and investigations, PBMs often terminate pharmacies from their pharmacy network.  For independent pharmacies, PBM termination is a devastating outcome especially when such termination was effectuated by any of the three largest PBMs, Caremark, Express Scripts, and OptumRx.  Pharmacies can be terminated from seeking readmission for one to five years, or even more.  

In the event of termination, pharmacies should begin preparing for readmission into PBMs’ network immediately following the termination. PBMs track history of audits and investigations.  Thus, it is imperative that pharmacies demonstrate, when seeking readmission into PBMs’ pharmacy network, that they took the necessary steps to “cure” any and all discrepancies that formed the basis of termination. PBMs have alleged many different types of discrepancies as the basis of their decision to terminate pharmacies and require a waiting period before applying for readmission.  In the recent past, PBMs have focused on pharmacy’s mailing practice while on a retail-contract, copay policies and procedures, bona fide physician-patient-pharmacy relationship, and inventory.  When seeking readmission into PBM network, the pharmacy should be able to articulate and show that it has implemented adequate corrective action plans as well as more thorough policies and procedures. PBMs then consider whether to invite the pharmacy to reapply for network participation, as well as how long pharmacies must wait before being readmitted. 

How Frier Levitt Can Help
PBMs will not allow terminated pharmacies to re-join their network unless the pharmacy has taken the steps to prevent recurrence of shortfalls that led to termination.  In this vein, pharmacies should consult with industry experts to start preparing for PBM network readmission immediately.  If your pharmacy was terminated by a PBM, contact Frier Levitt today to speak to an attorney. Frier Levitt offers several Flat Fee services including PBM Readmission.

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