OptumRx, among other PBMs, requires pharmacies to complete a credentialing process when applying to join its pharmacy networks. OptumRx, however, also has an Enhanced Credentialing Application process which is a more rigorous version of the standard pharmacy network credentialing that pharmacies may be subjected to. This applies when the pharmacy is a newly established entity with limited operational history, has a high volume of specialty/high-cost drugs, is situated in a high-risk area of concern, or operates via mail order or online, etc. This process is particularly for pharmacies that are located either in or around “HEAT Zones” as well. Briefly, in 2009, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) was created to utilize Medicare data analysis to increase community policing, and as a result, “HEAT Zones” were identified as geographic areas that are often associated with an increase in fraud, waste, and abuse. Pharmacies that are located in HEAT Zones should be aware of the Enhanced Credentialing Program.
The Enhanced Credentialing Application can be time-consuming and involves a deep dive into the pharmacy’s records by requiring responses to detailed questions, as well as extensive supporting documentation. The Enhanced Credentialing Application also usually involves drug inventory reconciliation whereby the drugs purchased are compared to those dispensed for a particular time period. For independent pharmacies, this credentialing process can be burdensome as it requires the pharmacy to gather purchase data from all of its wholesalers, distributors, and suppliers for a specified time period, along with matching dispensing records so that OptumRx can complete an invoice reconciliation.
Further, if after submission, OptumRx determines that the information and documents submitted by the pharmacy are insufficient or incomplete, OptumRx will deny admission into the network, and pharmacies are often met with difficulty in appealing the denial. Specifically, if OptumRx identifies inventory discrepancies or billing issues—such as incorrect NDC submissions, even if the errors did not affect insurance billing or patient dispensing—the pharmacy may be excluded from the network. In addition, during such inventory reconciliations, OptumRx is often reviewing a pharmacy for inventory shortfalls for a specific time period, or even daily (called point-in-time discrepancies). Specifically, Frier Levitt has observed that discrepancies like inventory shortfalls or incorrect NDCs (even for cash paying patients) have become the most common basis for credentialing denials. As such, pharmacies should remain vigilant and maintain ongoing inventory accuracy and compliance even before seeking admission into the network.
Pharmacies should also expect the possibility of a full, onsite credentialing review along with a request to provide substantive responses to a credentialing questionnaire. It’s important for pharmacies that undergo an on-site review to know that OptumRx is reviewing the pharmacy for compliance with OptumRx’s terms and conditions, even though the pharmacy is not yet a provider.
Lastly, Frier Levitt has also observed an increase in denials where pharmacies have failed to update their information submitted in credentialing applications, despite not clearly being informed to do so by OptumRx. For example, should pharmacies have any changes in their staff since the date its application is submitted, there may be an expectation that the pharmacy applying for admission update its application with the information of any new employees. This is important to note as something seemingly minor can lead to a network denial, requiring a pharmacy to wait a year prior to re-applying.
How Frier Levitt Can Help
If you are experiencing the denial of a credentialing application or are seeking new admission or a reapplication after a denial, and need assistance, please contact us today. We have a team of attorneys focusing on PBM matters that can help cure the shortfalls, appeal the decision, and prevent future admission denials.
Senior Counsel
