Humana Pharmacy Solutions (“Humana”) is a Pharmacy Benefit Manager that is wholly owned by Humana Inc., one of the largest health insurance companies. Humana maintains a network of pharmacies for its Plan Sponsor clients and regularly conducts Audits and Fraud, Waste and Abuse Investigations. Audits and Fraud, Waste and Abuse Investigations can result in penalties including, without limitation, reimbursement clawback, adjudication suspension, payment suspension, and network termination. In certain instances, Humana reports its Audit and Fraud, Waste and Abuse Investigation results to government agencies.
Humana Audit and Investigative Findings/Penalties
Humana will often review claims-specific information, requesting documentation on a certain group of prescriptions (typically for claims submitted in the past two years of the Audit/Investigation), but may often request non-claims-specific information, such as purchase history records. Examples of documentation routinely requested by Humana as part of an Audit include:
- Photocopies (front and back) of original hardcopy prescriptions and computer-generated label;
- Signature logs;
- Delivery logs with tracking information for mailed or home/business delivered prescriptions;
- Documentation demonstrating patients’ consent to fill their prescriptions by the Pharmacy;
- Wholesaler name and contact information;
- All records showing drugs purchased or transferred to or from other pharmacies;
- Proof of copay collection
- Signed prescriber or patient attestations;
- Ownership information; and
- Policies and procedures
Based on Humana’s review of the documents provided by the pharmacy, Humana will issue Initial Results that include Pharmacy Review Report. In the Initial Results, Humana will assign certain discrepancy notes to each alleged discrepant claim. Common discrepancy notes, and the supporting documentation, include the following:
| Notes/Description | Supporting Documents |
|---|---|
| Missing Prescription Copies (Pharmacy did not supply prescription copies) | Prescription Copies or Prescriber statement validating prescriber’s authorization. |
| Member Request Denial (Pharmacy did not supply patients’ consent to fill their prescriptions by the Pharmacy) | Member statement |
| Member Receipt Denial (Pharmacy did not supply patient signature logs or delivery) | Member statement |
| Missing Proof of Payment (Pharmacy did not supply copies of proof of payment) | Member statement or Proof of collection of copayment |
| Prescriber Denial (Pharmacy did not supply prescriber statements confirming the validity of prescriptions) | Prescriber statement |
| Drug Invoice Shortage (Pharmacy did not provide purchasing records supporting the claims billed) | Wholesalers’ invoices or pharmacy-to-pharmacy transfer |
Challenging Humana Audit and Investigative Findings/Penalties
Pharmacies facing Humana’s Audits and Fraud, Waste, and Abuse Investigations should review Humana’s Pharmacy Provider Manual in order to gather the requisite documentation. It is also important to note that the pharmacies are required to submit supporting documentation within the timeframe specified in the Audits and Fraud, Waste, and Abuse Investigations. Otherwise, Humana may not consider the documents when rendering its Audit/Investigative Findings.
Humana may impose additional penalties upon the pharmacies, even before a pharmacy has an opportunity to address Final Audit/Investigative Findings, such as Payment Suspension (where Humana temporarily suspends payments on claims while the pharmacy is allowed to submit claims), Adjudication Suspension (where the pharmacy is temporarily prohibited from submitting claims to Humana, or Pharmacy Network Termination (where the pharmacy is terminated from Humana’s Pharmacy Network for a set period). These penalties often must be appealed separate and apart from the underlying Audit/Investigative Findings that formed the basis of the penalties.
Speak with Seasoned Pharmacy Attorneys Today
PBMs clawback the entire amount of reimbursement on claims that were already dispensed by pharmacies. Moreover, PBMs often issue additional penalties such as Payment Suspension, Adjudication Suspension, and Network Termination. These not only cause significant financial harm but also disrupts the pharmacy’s day-to-day business.
Frier Levitt and its attorneys including clinician-attorneys have been have been assisting pharmacies throughout the country on a variety of legal issues including, but not limited to, disputing Payment Suspension, Adjudication Suspension, Network Termination, Audit Findings, Fraud Waste and Abuse (“FWA”) Investigative Findings, and Government Investigations. Contact Frier Levitt today to speak with an experienced Pharmacy Attorney today.