Frier Levitt achieved a significant victory by overturning the denial of a Florida pharmacy’s application for access to a major pharmacy benefit manager’s (PBM) provider network. The pharmacy is located in a Heat Zone, as defined by the Centers for Medicare and Medicaid Services (CMS). Originally, the PBM denied the pharmacy’s application based on alleged inventory shortages of multiple drugs identified by an invoice reconciliation, and most critically, the pharmacy’s failure to disclose certain information explicitly requested by the credentialing application. Specifically, the pharmacy was alleged to have failed to disclose information related to pharmacy’s personnel and common associations with other entities. As a result of these concerns, the PBM denied the pharmacy’s application seeking access to its provider network.
With the help of Frier Levitt attorneys, the pharmacy was able to successfully negate the appearance of the inventory shortfalls and address the discrepancies in the application, ultimately gaining admission to the network.
The pharmacy’s experience underscores the importance for pharmacies to ensure the accuracy of information provided during the PBM credentialing process. While the credentialing process can seem unduly burdensome, it is important for pharmacies to ensure that the information provided is completely accurate. This includes the disclosure of all requested information, as many credentialing denials rest on the failure to disclose relevant information, even where the information itself is not necessarily problematic. In these situations, the PBM may perceive the failure to provide information as attempts to bypass credentialing requirements or conceal information that may otherwise affect the PBM’s decision to admit the pharmacy into its network. Therefore, it is important for pharmacies to accurately provide all of the information requested by the application, and to regularly update any pending applications (i.e., revised list of employees if there are changes since the time the application was submitted). The failure to do so may result in a denial of the pharmacy’s application, or even when a pharmacy is able to successfully appeal a denial on these grounds, it causes unnecessary delays in the pharmacy’s network admission.
How Frier Levitt Can Help
If your pharmacy is currently in the process of applying to a PBM network or has recently been denied after submitting a network credentialing application, the experienced attorneys at Frier Levitt can assist you. Contact us to speak with an attorney who can provide valuable guidance and support.
