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Hiring a Law Firm at the Start of a PBM Audit or Credentialing Application Can Boost Your Bottom Line

Navigating a Pharmacy Benefit Manager (PBM) audit or enrollment application on your own can be overwhelming. PBM audits rely on voluminous requests for documentation under strict and tight deadlines. Incomplete or late responses will guarantee financial chargebacks and risk more catastrophic consequences, including payment suspensions or network terminations. Successfully navigating PBM enrollment applications is critical to creating and maintaining a thriving business.

Even though the stakes are high when responding to PBM audits or navigating enrollments, clients often express concerns over the cost of hiring a law firm. The cost of being denied enrollment or six figure audit chargebacks is far greater. The best chance for bottom-line success in audits and enrollments is providing a complete and timely audit appeal or enrollment application on day one. Unraveling audit findings or an enrollment denial is possible but requires more work and coordination to overcome, creating additional, preventable costs.

Boesen and Snow has seen an increase in pharmacy clients who have hired non-attorney consultants for PBM audit responses and credentialing. Consultants may appear affordable, until an enrollment denial or audit chargeback overwhelms the apparent savings.

Recently, a client hired Boesen & Snow to appeal a PBM enrollment denial for common association to individuals and pharmacies with PBM terminations. The client had purchased a pharmacy that had obtained its state permit only two months earlier, which had no PBM contracts, no staff, and no dispensing history. The client utilized a third-party consultant to complete the enrollment applications for two major PBMs and after reviewing the applications, the consultant made multiple errors. Not only did the consultant provide inaccurate information, but it was ultimately linked to the bad actors. In this case, the client paid over $100,000 for two enrollment applications that the PBMs denied, which resulted in additional legal expense to unravel the damage the consultant caused. Consulting fees of this amount, or consultants who guarantee results, should be met with great skepticism.

Another client utilized the “PBM Audit” services that their PSAO provided. Throughout the audit process, the PSAO service provided incomplete documentation, resulting in audit discrepancies. During a final appeal process unique to the auditing PBM, the PSAO service provided conflicting documentation and discrepancies remained. The PSAO’s audit services clearly lacked the legal knowledge and ability of experienced pharmacy law attorneys to properly represent the client.

Boesen & Snow represents pharmacies in all stages of the PBM audit and enrollment process. This includes offering a proactive Audit GAP Analysis or pre-enrollment preparation beforehand to prevent negative audit findings or terminations, as well as defending pharmacies against PBM audit clawbacks, terminations, and enrollment denials. It is important that you engage experienced pharmacy law attorneys early before problems arise and critical that you rely on experienced, professional assistance if it is too late and the PBM has already taken adverse action. If a PBM has recently audited your pharmacy or you want to engage in the enrollment process, contact Boesen & Snow today for a complimentary initial consultation.

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