Frier Levitt Successfully Resolves Demand for Overpayment from Major Plan Over Prior Authorization Concerns

Frier Levitt successfully helped a Louisiana-based pharmacy resolve a finding for overpayment from a large insurance plan, who demanded a significant sum of money be returned to the plan on the basis that prior authorizations obtained by the pharmacy for a handful of prescriptions were invalid. Specifically, the health plan alleged that the prior authorizations for a number of identified claims were improperly submitted by the pharmacy with inaccurate information regarding the patients’ treatment and that the pharmacy represented itself to the plan as though they were the representatives of the prescriber.  As a result, the health plan sought immediate recovery for the identified claims without providing the pharmacy an opportunity to appeal such findings. However, with the help of Frier Levitt, the pharmacy was able to successfully establish the validity of the prior authorizations and the way they were submitted. As a result, the plan rescinded its demand for overpayment and resolved the matter in full.

Many PBMs and health insurance plans have prior authorization policies that identify specific procedures that pharmacies, prescribers, and patients are required to follow to submit a valid prior authorization request. While specific procedures may vary, all prior authorizations serve the same purpose – to ensure that the medication being prescribed is medically necessary based on the patient’s treatment plan and medical history.

That said, payors will still require in addition to ensuring that the underlying information submitted for a prior authorization request is valid, that such information is submitted pursuant to the procedures outlined by the payor. Therefore, it is crucial that pharmacies take extra precautions to comply with the prior authorization requirements of all contracted payors to ensure the validity of prior authorizations and claims submitted, and to avoid any potential requests for overpayment or allegations of invalid prior authorization.

How Frier Levitt Can Help

If your pharmacy has involvement with the prior authorization process, it is important to consult an attorney to have your pharmacy’s policies reviewed. It is also important to consult an attorney before making any payments towards overpayment allegations raised by a PBM or plan to confirm whether the request for recovery is valid and warranted by the PBM or plan.