OptumRx is a Pharmacy Benefit Manager (“PBM”) wholly owned by UnitedHealth Group. As a PBM, OptumRx maintains a network of pharmacy providers who service OptumRx’s patients. OptumRx monitors performance of their network pharmacies through various means including, without limitation, routine on-site (now virtual amid COVID-19 pandemic) and desktop audits. The Audit Findings may result in significant chargeback on prescription claims that were already dispensed by the pharmacies. Audit Findings can lead to Payment/Adjudication Suspension as well as Pharmacy Network Termination. It is also worth noting that OptumRx is well known for its enhanced credentialing/credentialing and readmission procedures. Therefore, it is imperative that pharmacies receive requisite counseling and assistance from Pharmacy Attorneys.
OptumRx Audit Findings/Penalties
OptumRx Audits can be overwhelming for pharmacies. It is the pharmacy’s responsibility to provide documents requested by OptumRx as well as submit a robust appeal to OptumRx in response to Audit Findings. If OptumRx determines that the supporting documents submitted by the pharmacy are insufficient, then OptumRx will clawback the entire reimbursement amount of the claims and may impose additional penalties (including network termination).
During a routine audit, OptumRx will review specific information about a certain group of prescriptions and request a host of documents from the pharmacy. Examples of documentation routinely requested by OptumRx as part of an Audit include:
- Photocopies (front and back) of original hardcopy prescriptions/physician order sheets including back-slaps or any computer-generated stickers.
- Dispensing records including refill records.
- Prescription Signature Logs/Proof of Delivery.
- Compound formula worksheets.
- Professional licenses and certificates.
- List of Wholesalers/Distributors (including Reverse Wholesalers).
- Ownership Information.
OptumRx will also perform an invoice reconciliation for all purchase records and tally the records to verify whether the quantity purchased by the Pharmacy was sufficient to support the claim processed by the Pharmacy.
Based on OptumRx’s review of the documents provided by the pharmacy, OptumRx will issue Audit Findings, which are generally separated into two parts, Section I (Prescription Findings) and Section II (Invoice Reconciliation).
Some of the examples of the OptumRx’s Audit Findings in Section I (Prescription Findings) that may result in full/partial recoupment of claims include the following:
| Discrepancy | Supporting Documents |
|---|---|
| DAW | Failure to provide documents supporting use of a particular Dispense As Written (DAW) code. |
| Invalid Prescriptions | Failure to provide supporting documents to cure deficiencies noted in the prescription. For example, Ohio State law requires that prescriptions, among other things, not be coded in such a manner that it cannot be dispensed by any pharmacy of the patient’s choice.1 |
| Misfill | Failure to provide documents that justify filling the prescription. |
| Missing Prescription | Failure to provide hardcopy prescription or equivalent documents. |
| No Signature Log | Failure to provide signature logs signed by patients or patient representatives. |
| Incorrect Quantity | Failure to provide documents that support quantity billed when it is different than the quantity prescribed. |
| Unauthorized Refill | Failure to provide documents that support filling refills. |
| Unauthorized Mailing | Failure to provide documents that justify mailing prescriptions outside of the state where the pharmacy is located. |
In Section II (Invoice Reconciliation), OptumRx provides a list of medications and the respective drug invoice shortage amount. It is imperative to note that OptumRx’s findings in Section II are based on the review of the invoices and purchase summaries provided by the pharmacy’s wholesalers. However, OptumRx does not provide National Drug Codes for the medications subject to drug invoice shortage discrepancies.
Challenging OptumRx Audit Findings/Penalties
PBMs often clawback the entire amount of reimbursement on discrepant claims, which have already been dispensed by pharmacies. OptumRx is no exception. Indeed, after issuing Audit Findings and recouping the entire amount of reimbursement on claims from the pharmacies, OptumRx may impose additional penalties in the form of Payment/Adjudication Suspension and/or Network Termination. That notwithstanding, pharmacies have certain rights available to them under the contract documents and applicable law to dispute Audit Findings.
When facing OptumRx’s Audits, pharmacies should review OptumRx’s Pharmacy Provider Manual and Audit Findings in order to compile the requisite supporting documentation to contest alleged discrepancies. Importantly, types of supporting documents required to reverse Audit Findings vary depending not only on the discrepancy type, but the drug product at issue. For example, OptumRx requires that pharmacies must purchase pharmaceutical products and supplies, for the claims submitted to OptumRx, from a course that is both ABP Drug Distributor Accreditation (formally known as VAWD) and licensed as drug wholesaler. In addition, OptumRx’s Pharmacy Provider Manual sets forth a specific time frame for the pharmacy to submit the evidentiary materials for OptumRx’s review. Failure to respond to audit requests or other non-compliance with OptumRx’s Provider Manual and appeal processes may result in clawbacks as well as other penalties.
To reiterate and reemphasize, OptumRx may impose additional penalties upon the pharmacy besides taking back the reimbursement amount paid on the discrepant claims. Such penalties may include Payment Suspension (where OptumRx 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 OptumRx), or Pharmacy Network Termination (where the pharmacy is terminated from OptumRx’s Pharmacy Network for a set period, which may range from 1 year to 5 years). When facing the aforementioned penalties, pharmacies must utilize tools available to them including, without limitation, Prompt Pay laws and Any Willing Provider laws.
1) OAC 4729-5-30(B)(13).
Speak with Seasoned Pharmacy Attorneys Today
Dealing with a PBM audit is a daunting task. It becomes more challenging when PBMs such as OptumRx require documents that are not readily available from the pharmacies and unilaterally decide types of documents that are “reasonably necessary” that allegedly would demonstrate the pharmacy’s compliance.
Frier Levitt has a deep bench of experienced healthcare attorneys, including several pharmacist- and clinician-attorneys, who 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.