Pharmacy Benefit Managers (PBMs) regularly audit and review pharmacies for their participation in their networks, and as part of that review, PBMs ensure that pharmacies are acting in a manner consistent with the terms and conditions identified by the PBM under its Provider Agreement or Manual. Pharmacies should be aware of the particular policies that PBMs have established to ensure compliance. One such term is the requirement that pharmacies timely reverse prescriptions if the prescription is not picked up or delivered to the patient within a particular period.
Most, if not all, PBMs, identify a time period for when unclaimed prescriptions must be reversed and returned to stock after dispensing the prescription. In the event that the pharmacy did not dispense medication to the patient and untimely reversed the claims outside the allocated timeframe, PBMs may subject the pharmacy to a full recovery of the claim, even if the claim was ultimately reversed by the pharmacy outside of the allocated time period. As such, pharmacies should be aware of “Return to Stock” requirements. Pharmacies must ensure that the date a claim is billed is the date the prescription is also dispensed to the patient. If a patient does not pick up a prescription ordered by the provider within the allocated timeframe, the pharmacy should reverse the claim submitted to the PBM and only rebill the claim upon dispensing to the patient. PBMs suggest that when a pharmacy does not adhere to timely reversals, there is an unnecessary cost to the PBM and, in turn, the plan, for paying for the pharmacy for claims not ultimately dispensed. PBMs pay on the claim before the pharmacy’s dispensing, though such cost is ultimately recovered when a pharmacy reverses the billed claim. To that end, if a pharmacy does not have medication on hand but submits a claim for the prescription, the pharmacy should be aware that the timeframe to dispense the prescription begins at the time the claim is submitted, not when the prescription is dispensed, as PBMs require the prescription be filled the same day the claim is filed, as mentioned above.
It’s important for pharmacies to balance a meticulous and calculated workflow focused on avoiding dispensing any medications without the patient’s authorization while adhering to proper claim reversal requirements. Of note, a pharmacy should review its claims and ensure that any claims for which a prescription is not dispensed to the patient within a certain timeframe are reversed and, if need be, rebilled once the medication is dispensed correctly. All pharmacy staff members must be properly trained on claim reversal processes and return-to-stock procedures, and pharmacies should understand that untimely reversals are likely to result in claim recoupment. Untimely claims reversals may even result in termination from the PBMs’ network, particularly if there is a pattern of untimely reversals well outside the required timeframe. PBMs are likely to find that a pattern and practice indicative of a failure to properly reverse claims are not an inadvertent or minor clerical error but rather a blatant disregard for the PBM’s Provider Manual and suggestive of fraud, waste, or abuse.
What to Do if Your Pharmacy Is Audited or Investigated by a PBM?
Pharmacies that undergo any investigation or audit with a PBM are cautioned to take proactive efforts to resolve discrepancies such as claim reversals as unresolved findings may lead to claim recoupment and, if undisputed, possible termination. Pharmacies should maintain an operational practice to reverse and rebill all prescriptions determined to have been billed in error and conduct periodic self-audits to ensure compliance with all Federal, State, and PBM requirements.
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 these results.
