Frier Levitt succeeded in obtaining a complete reversal of audit findings for a Florida home infusion pharmacy where the PBM alleged close to $750,000 in discrepancies associated with approximately 50 different claims. The audit discrepancies focused on particular clinical decision-making by the professional staff at the pharmacy, and Frier Levitt was able to leverage arguments citing to the new Florida PBM audit law, where certain audits requiring the clinical and professional judgement of a pharmacist must be conducted by a pharmacist. Here, the PBM audit was not conducted by a pharmacist. In addition, Frier Levitt attorneys successfully challenged the PBM’s prior refusal to accept post-audit documentation (the PBM had conflated “post-dispensing” documentation – which the PBM would not accept – with “post-audit” documentation). Finally, since the audit involved issues related to professional pharmacy practice, Frier Levitt was able to effectively utilize the clinical acumen and proficiency of its numerous pharmacist attorneys. Drawing from their extensive experience in pharmacy settings, Frier Levitt attorneys demonstrated that the PBM’s positions were unsupported.
Among other things, this audit highlighted that often times, typical PBM auditors accustomed to auditing retail pharmacies lack the knowledge and understanding of the unique nature of home infusion pharmacies. They are prone to misunderstandings and errors regarding the documentation being reviewed and the process of how home infusion pharmacies provide care. Home infusion pharmacies facing PBM audits must be cautious to ensure that the PBM auditors’ lack of knowledge does not result in audit recoupments or worse. For assistance, contact Frier Levitt today.
