Frier Levitt recently assisted a California-based pharmacy client in successfully challenging a major PBM’s audit findings and reversing 100% of the purported discrepancies. During the audit, the PBM asserted allegations involving patient solicitation and inaccurate prior authorization forms. Under Frier Levitt’s guidance, the pharmacy gathered supporting documentations, and our attorneys submitted an appeal response highlighting the relevant facts provided by the pharmacy. After receiving the appeal response, the PBM reversed every alleged discrepancy and did not seek to recoup any funds from the pharmacy.
PBMs often attempt to use routine audits as a tool to seek unwarranted recoupment of funds from their contracted pharmacies. Oftentimes, there are stringent requirements on what documents will be deemed sufficient to overturn discrepancies. Consequently, even when certain discrepancies may not actually exist, PBMs will refuse to reverse any alleged discrepancies without the precise documentation it requested. As such, pharmacies must ensure they implement policies and procedures design to retain the types of documents PBMs request during audits to avoid any unwarranted discrepant findings.
In addition, when a PBM audit results in discrepant findings, pharmacies must ensure they utilize the contractual appeal process outlined in their agreements and PBM Manuals to combat any and all audit findings, regardless of the amount at issue. Critically, failure to contest discrepant audit findings, even ones that place only a seemingly insignificant amount of moneys at issue, could lead to a pharmacy’s termination from a PBM’s network. Indeed, PBMs track each pharmacy’s audit history and, in an alarmingly increasing frequency, rely on past audit results to justify terminating a pharmacy (we have seen PBMs rely on up to six-year-old audit findings). Thus, even though smaller audit amounts may not seem to be “worth” disputing, failure to do so may serve as the basis for severe PBM sanctions in the future, including, but not limited to, network termination.
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 sciences 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.