Frier Levitt recently assisted a California-based independent pharmacy that faced an audit from a major pharmacy benefit manager (“PBM”) by successfully challenging the audit findings and reducing the audit discrepancies by $159,438.46. During the audit, the PBM identified nearly three hundred (300) claims as discrepant due to a host of alleged issues including copay collection discrepancies, drug invoice shortages, missing signature logs and prescriber denials. Under Frier Levitt’s guidance, the pharmacy gathered the requisite documentation, and our attorneys submitted the successful appeals to the PBM on behalf of the pharmacy.
PBMs often attempt to use routine audits as a tool to seek unwarranted recoupment of funds from their contracted pharmacies. As discussed in our recent article, PBMs often impose stringent terms dictating which documents will be deemed sufficient to overturn alleged discrepancies. Thus, it is imperative that pharmacies have robust procedures to ensure they are properly retaining the appropriate documents to defeat unfounded PBM audits.
In addition, pharmacies should utilize the contractual appeal process outlined in their agreements with PBMs to combat any and all audit findings, regardless of the purported clawback amount. Oftentimes, pharmacies allow PBM audit findings to go uncontested due to seemingly insignificant amounts at issue. Critically, even if a PBM audit does not result in adverse action beyond the recoupment of monies from the pharmacy, PBMs keep track of their network pharmacies’ audit histories. Alarmingly, Frier Levitt has noticed an increasing trend where PBMs are using prior audit results as a justification to terminate the pharmacy if the pharmacy has another adverse finding years later. Though these smaller amounts may not seem to be “worth” disputing, failure to do so may serve as the basis for severe PBM sanctions, including network termination in the future.
How Frier Levitt Can Help
Regardless of the size of your pharmacy or the amount at stake, Frier Levitt is ready and able to assist you in successfully challenging a PBM’s audit of your pharmacy. Our life science attorneys are prepared to provide guidance as your pharmacy prepares for PBM audits as well as provide an aggressive approach to fight for your rights following a PBM audit. If you have any questions or need help fighting a PBM audit, contact us to speak to an attorney.
