Frier Levitt recently helped a Connecticut-based independent pharmacy that was being audited by a major PBM by successfully challenging the audit and reducing the audit discrepancies by more than 90%. During the audit, the PBM requested a host of documents including: (i) photocopies of prescriptions; (ii) dispensing records including refill records; (iii) prescription signature logs/proof of delivery; and (iv) list of wholesalers/distributors. The PBM also conducted invoice reconciliation by comparing drugs purchased and the amount of corresponding drug claims billed to the PBM.
Despite the pharmacy having provided the requested documents, the PBM issued initial audit findings wherein it alleged drug invoice shortages (claiming that the pharmacy did not have enough inventory of products than the billed amount). The pharmacy then engaged Frier Levitt to further appeal the audit findings – by utilizing the contractual appeal process – and our attorneys were able to successfully reduce the audit discrepancies by more than 90%.
Oftentimes, pharmacies allow PBM audit findings to go uncontested due to smaller clawback amounts. 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. Increasingly, PBMs are using prior audit results as justification to terminate the pharmacy years after the pharmacy has another adverse audit finding. Though the smaller amounts may not seem to be “worth” disputing, failure to do so may serve as the basis for network termination by a PBM somewhere down the road.
The Frier Levitt team was led by Dae Lee and included counsel by Adam Farkas.
How Frier Levitt Can Help
Regardless of the size of your pharmacy or the amount at stake, Frier Levitt is ready to assist you in successfully challenging the audit. Our attorneys include clinicians who are prepared to take an aggressive approach to fight for your rights following a PBM audit. If you have questions or need help with a PBM audit, contact Frier Levitt today to speak to an attorney.