Frier Levitt Successfully Reverses 100% PBM Audit Findings for Michigan Pharmacy

Frier Levitt successfully reversed one hundred percent (100%) of the audit findings issued by a major PBM against a Michigan-based pharmacy. During the audit, the PBM asserted a host of allegations against the pharmacy. 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. Often, 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 they requested. Therefore, pharmacies must implement policies and procedures designed 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 money 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. 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.  By retaining legal representation and taking prompt action, pharmacies not only avoid significant economic and reputational harm, but ensure uninterrupted services to their patients.

How Frier Levitt Can Help

If your pharmacy has recently received an audit request or has received findings related to a previous audit, Frier Levitt can help ensure that the documents you submit to your PBM are responsive to their request or help to reverse the alleged discrepancies.  If you have any questions or need help fighting a PBM audit, contact us to speak to an attorney.