With the help of Frier Levitt attorneys, an independent pharmacy in Hawaii can continue participating in a major PBM network. Following an investigative audit, the PBM identified alleged discrepancies and sought recovery potentially leading to the pharmacy’s termination from the network.
To avoid termination from the network, the PBM requested the pharmacy to identify root causes of the relevant findings and develop and implement a corrective action plan to address such root causes as a condition of its continued participation in its network. If the pharmacy did not satisfy the request from the PBM by providing a comprehensive overhaul of its policies, the PBM threatened to terminate the pharmacy from its network. Frier Levitt worked closely with the pharmacy to review its policies and procedures and develop corrective actions to prevent the alleged discrepancies from recurring. As a result, the pharmacy successfully maintained its network status, demonstrating its commitment to continued compliance.
This case is a clear demonstration that even minor adverse audit findings could threaten a pharmacy’s PBM network participation. While PBMs do often use adverse auditing findings as grounds for termination, there are alternative disciplinary measures that PBMs may choose to take against providers following the conclusion of an audit. Although such a request is preferable to termination, a positive result is not guaranteed. Due to the vague and often generic nature of these requests, creating a corrective action plan that satisfies a PBM’s request can be difficult.
Accordingly, it is not uncommon for PBMs to reject the submitted corrective action proposals, asserting non-compliance with their requirements and proceed with termination of the pharmacy. Fortunately, Frier Levitt attorneys’ experience in handling such matters enabled, the pharmacy to develop a corrective action plan that met all PBM requirements and resulted in a swift resolution.
Importantly, not all audit discrepancies are accurately alleged against a pharmacy. Pharmacies should carefully review audit findings, identify the root causes of such results, and determine whether or not discrepancies exist. If there is no discrepancy and the PBM is falsely identifying one, a pharmacy should explore any administrative and legal options available to challenge such discrepancies, as unresolved discrepancies could result in further action, including, but not limited to, termination from a PBM network.
How Frier Levitt Can Help
If your pharmacy has received a PBM request for the implementation of corrective action measures or has recently received audit findings that you believe are likely to result in further disciplinary action, contact us to speak with an attorney today.
