As previously noted by Frier Levitt attorneys, PBMs are becoming increasingly more stringent regarding consideration of documentation and records demonstrating the remittance of copayments. To be clear, it is typical for PBMs to request documents and records proving that its providers have collected the proper copayments from members as an additional way to ensure the validity of the claims submitted by pharmacies. Accordingly, pharmacies have routinely submitted, and PBMs routinely accepted, receipts generated at point-of-sale which showed the prescription number as well as the date and time that the transactions occurred. Recently however, receipts that merely show that patients paid for their prescriptions is simply not enough. Beyond proving that patients have paid their prescriptions through these register receipts, PBMs are requiring additional evidence that specifically shows that providers have collected the copayments remitted by their members. For example, where a receipt demonstrates that a patient paid for their prescription with a credit card, PBMs now also expect providers to submit individualized reports from their credit card merchants demonstrating the authenticity of the underlying transaction, and more importantly that those funds were in fact processed and received by the provider. Alternatively, where a receipt demonstrates that a patient paid for the prescription in cash or check, PBMs may now expect providers to submit bank statements demonstrating that those funds were successfully deposited into a provider’s account.
Therefore, while ensuring the proper maintenance of documentation relating to services provided to PBM members has always been instrumental for ensuring compliance with PBM audits, the maintenance of documentation specific to the collection of copayments is even more crucial. Accordingly, pharmacies should be sure to implement policies and procedures to ensure that such documentation is strictly maintained, or reviewing any existing policies and procedures to ensure that the documents they are maintaining will be deemed sufficient by their PBMs. In particular, pharmacies should be sure to clearly define the process for accepting check or cash payments, as the nature of these types of transactions commonly trigger additional scrutiny from PBMs.
Similarly, instances where there is no copayment paid by a patient can also trigger scrutiny, as the ability of providers to waive copayments is explicitly limited by the terms and conditions of their PBM agreements. In order to establish that pharmacies did not improperly waive copayments or fail to collect copayments which should have been otherwise paid, pharmacies should be sure that their policies and procedures also lay out a clear process for determining if and when such waivers can be granted. Alternatively, where there has been no waiver, a lack of copayment attributable to the application of manufacturer coupons, or other financial assistance programs should be documented as well. Therefore, pharmacies should be sure that their policies require the maintenance of records or notes in patient profiles that can be submitted to PBMs in order to show that no copayment was required to be collected. In addition to ensuring that the required documents are readily available for review by PBMs in the event of an audit, as it has been increasingly common for PBMs to request copies of a pharmacy’s copayment collection policy during an audit or at the time of credentialing, comprehensive policies themselves can be used as further evidence of a pharmacy’s efforts to collect copayments where required.
How Frier Levitt Can Help
If your pharmacy is currently being audited, has recently been issued audit findings alleging instances where copayments were not collected from patients, or is just generally concerned that your pharmacy’s current practices regarding copayment collection may be deficient, Frier Levitt can help. Contact us to speak with an attorney today.
