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PBM Audits and Member Denied Claims: How PBMs May Be Leading Patients Down the Path to Deny Claims Submitted for Reimbursement by Your Pharmacy.

Boesen and Snow Law has observed an increasing number of PBM audits containing “Member Denied” claims including:

  • Member Denied Paying Copayment
  • Member Denied Receiving Medication
  • Member Denied Requesting Medication

The trend has shown that currently, Member Denials can be nearly impossible to overcome despite refuting evidence and have increasingly led to the termination of Pharmacies’ Provider Agreements. Further complicating an effective audit response is the refusal by the PBM to provide evidence including the documentation or methods utilized in obtaining the Member Denials.

Recently, a LinkedIn post made in December 2021, shed new light on the methods utilized by PBMs when determining Member Denied claims. The post was made by a patient who had received medications and happened to have experience working in Specialty Medication Access. The post included photographs of the letter received by the PBM which listed the pharmacy’s name and requested the patient refer to the original printed label when answering the following questions:

  • Have you been treated by the following physician(s)?
  • Did you receive the following medications from [Pharmacy Name}?
    • RX Number, Date of Fill, and Quantity
  • Did you request or authorize this RX?
  • Did you pay the listed co-pay?
  • How did you receive the medication(s)?
    • In-Store (by you)
    • In-Store (by someone else)
    • Mail Service (UPS, FedEx, USPS, etc)
    • Home Delivery (delivered by pharmacy employee)
    • Other/Unknown

The post commented on the difficulties faced when attempting to answer the PBM’s questions, even with prescription knowledge that the average patient may be lacking. This included finding the label for and recalling prescriptions that were over a year and a half old, recalling the telemedicine prescriber’s name, and the co-pay amount paid. This is important, as patients may be hesitant of answering “Yes” due to the age of the prescriptions listed or inability to recall specific details. Furthermore, it is unclear at this time if partial responses or non-responses are actually considered denials by the PBMs. Member Denied Claims have increasingly been utilized as the basis for PBM Pharmacy Network Terminations and could severely affect your Pharmacy business. Contact Boesen and Snow Law today for guidance on responding to audit findings that include Member Denied Claims.

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