While the recoupment of reimbursements alone is typically a motivating factor for pharmacies to appeal PBM audit findings, it should not be the only factor considered. Regardless of the actual dollar amount at issue, leaving discrepancies unresolved poses greater risks to pharmacies’ network participation. PBMs will often use any unresolved discrepancies to justify taking further disciplinary action against providers, regardless of the monetary amounts associated with such discrepancies. In particular, PBMs may attempt to terminate pharmacies from their networks by citing concerns identified in recent audits, even where pharmacies may have been able to reverse a majority of the alleged discrepancies. Accordingly, pharmacies should continue to press for a reversal of any and all unresolved discrepancies, even if they recover a substantial amount of the audit findings. Specifically, pharmacies should be sure to exhaust any and all administrative appeal rights provided under the terms of their provider agreements, as well as any additional rights provided under applicated Federal and State laws.
In a recent case, with the help of Frier Levitt attorneys, Harini Bupathi and Andrea Hageman an independent pharmacy resolved over $200,000 of audit findings issued against the pharmacy by a major PBM. Of the almost $250,000 originally placed at issue, a majority of the discrepancies related to the pharmacy’s alleged failure to provide sufficient evidence demonstrating that the patients either received or requested the prescriptions reimbursed by the PBM. In particular, the PBM alleged multiple instances in which its members denied requesting and/or receiving prescriptions, despite the evidence which had been previously provided by the pharmacy which tended to negate these claims. Despite the signature logs, tracking histories, and receipts provided by the pharmacy in response to its original audit request which overwhelming demonstrated the prescriptions at issue were in fact received by and explicitly requested by its members, the PBM sought to recover the amounts already reimbursed to the pharmacy for the services already received by its members. However, with the help of Frier Levitt, the pharmacy has been able to reverse a majority of these discrepancies.
However, the work isn’t over. Despite this large reduction in the discrepant amount for this independent pharmacy, Frier Levitt continues to work towards the reversal of outstanding audit findings in their entirety, to ensure that the pharmacy is fairly compensated for the services provided to the PBM’s members, but more importantly, to ensure that the pharmacy’s position as a participating provider in the PBM’s network is secured.
This single circumstance reflects a broader trend in PBM audits, specifically concerning scrutiny over prescription documentation. With heightened frequency, Frier Levitt attorneys have observed PBMs’ disregard evidence supporting pharmacies’ claims of prescription receipt or request, instead PBMs favoring alleged denials of its members, often received years after the prescriptions at issue were dispensed or as a result of a misleading request for information from the members. Nevertheless, PBMs continue to rely on patients’ statements, even where pharmacies have clear evidence that the prescriptions were received and requested by these patients. Accordingly, it is important that pharmacies carefully review any guidelines or guidance offered by their PBMs to ensure that their documents contain all required elements so that PBMs have no basis to favor potentially false patient denials over pharmacy records.
How Frier Levitt Can Help
If your pharmacy is currently responding to an audit or has yet to formally respond to audit findings issued by a PBM, Frier Levitt can help. Contact us today to speak to an attorney.
