PBMs often conduct invoice reconciliation audits to ensure pharmacies maintain sufficient quantities of medications to support the quantities billed. Recently, a New York-based pharmacy was facing a large recoupment following a PBM invoice reconciliation audit when the PBM alleged the pharmacy did not have proper inventory. Despite the submission of the underlying invoice documentation and even pedigree, the PBM refused to consider the pharmacy's purchases on the basis of a...

Recently, Frier Levitt assisted a Florida-based pharmacy in a PBM audit that alleged the pharmacy had mailed into certain states without a valid non-resident licensure to do so. Frier Levitt was able to prove that the pharmacy did in fact maintain active nonresident licensures in several states or was not required to maintain licensure at the time of dispensing. In other instances, the pharmacy did not dispense medications to patients...

Frier Levitt recently assisted an independent pharmacy with a PBM audit in which the PBM claimed the pharmacy had inventory shortfalls for over twenty drugs. Frier Levitt reviewed the pharmacy's invoice documentation, and submitted an appeal on behalf of the pharmacy. While awaiting results of the appeal, the pharmacy received a notice of termination from the PBM based on the inventory shortfalls identified in the audit. Frier Levitt worked with the PBM...

Last month, the U.S. Department of Health and Human Services Office for Civil Rights (OCR) announced a resolution agreement it had entered into with Filefax, Inc. (Filefax) to address potential violations of the Health Insurance Portability and Accountability Act (HIPAA). By way of brief background, Filefax was a medical record storage and disposal company that offered its services to several covered entities. In early 2015, the OCR learned that not...

Within the past several weeks, pharmacies across the country have begun to receive notices of "non-compliance" from various PBMs, including Prime Therapeutics (Prime). For example, pharmacies were recently notified of Prime's 10% billing threshold for certain targeted drug products, such as compounds, non-FDA approved drugs, and single ingredient products used in compounds. The same correspondences list over 250 drug names subject to this billing threshold, greatly expanding these notices from...