Frier Levitt recently assisted a Florida-based retail pharmacy in overcoming a substantial number of discrepancies raised during a PBM audit. The PBM alleged that the pharmacy had several discrepancies, including invalid proof of a patient’s consent to fill/refill prescriptions, invalid proof of copayment, incorrect date written on the hard copy prescription, invalid state licenses, and unclear prescriptions submitted during the audit request.
Upon receipt of the initial audit results, Frier Levitt advised the pharmacy on the importance maintaining accurate and up-to-date records and state licenses and having documents readily accessible to produce in the case of an audit. The pharmacy’s recordkeeping errors identified at the audit request resulted in significant findings that have since been resolved. Frier Levitt assisted the pharmacy in providing documentation to demonstrate the members’ consent to fill the medication, along with proof of copayment collection, and additional attestations to validate the prescription.
In the audit, the PBM alleged significant discrepancies relating to an alleged failure to provide proof of copayment. Upon review of the discrepancies and the pharmacy’s records, Frier Levitt helped identify the PBM’s misinterpretation of copayment collection requirements as it relates to the patients at issue, which were all Qualified Medicare Beneficiaries” (“QMBs”). Pharmacies should be aware of their obligations of copayment collection concerning QMBs and seek legal counsel to develop further policies relating to copayment collection. Here, Frier Levitt worked with the pharmacy to provide relevant documentation and patient profile information confirming their “QMB” status to the PBM to resolve the audit results.
After working with the pharmacy to address the alleged findings, Frier Levitt successfully reduced all the results, except for four discrepancies for an alleged lack of patient consent. Through further exhaustive efforts guided by Frier Levitt, the pharmacy was ultimately able to resolve the remaining discrepancies in an additional appeal submission.
Pharmacies that receive any results which allege outstanding discrepancies are encouraged to engage in further communication with the PBM to resolve them, as unresolved findings may lead to termination. Further, pharmacies should maintain an accurate records relating to members’ consent to fill prescriptions and their payment towards any copayment obligations.
If your pharmacy is undergoing an audit or investigation and requires assistance, contact Frier Levitt to speak to an attorney. Frier Levitt’s attorneys have substantial experience and knowledge in the specific concerns that PBMs have regarding network access and have assisted numerous pharmacies in overcoming significant PBM audit findings.
