PBMs are constantly expanding and changing the scope of their audits to find new avenues for revenue generation and new grounds for network termination. One area that seems ripe for expanded scrutiny by the PBMs is Drug Supply Chain Security Act (DSCSA) track and trace documentation. In addition to checking the license status and FDA registration, …
Continue reading “PBM Audits – Is DSCSA Documentation The Next Trap for the Unwary?”
In successive weeks, Boesen and Snow has obtained two favorable decisions through a PBM’s Appeal Hearing Process that reversed Network Terminations due to audit findings. The firm collaborated with each client to prepare thorough responses to initial and final audit findings and termination appeal hearing presentations that convinced the PBM to quickly rescind the decisions …
Continue reading “Boesen and Snow Secures Back-to-Back PBM Network Termination Reversals.”
Don’t Wait! Build a relationship with an Experienced Pharmacy Law Team One of the more stressful parts of going through Pharmacy Benefit Manager (PBM) audit is that, by the time the average pharmacy hires experienced pharmacy law attorneys to defend their business, there may only be two weeks or less to formulate a successful response. …
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Boesen and Snow recently secured the reversal of a major PBM’s decision to terminate a pharmacy from its network. Before the reversal, the PBM had rejected the pharmacy’s documentation refuting the audit findings and had quickly issued its termination letter. Boesen and Snow collaborated with the pharmacy client to obtain and provide overwhelming evidence to …
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Both federal and state authorities are increasing the scrutiny and regulation of Pharmacy Benefit Managers (“PBMs”). In the U.S. Senate, Senator Chuck Grassley (R – Iowa) and Senator Maria Cantwell (D – Washington) have sponsored the Pharmacy Benefit Manager Transparency Act of 2022. The bipartisan bill would empower the Federal Trade Commission to increase drug …
Continue reading “Scrutiny of PBMs Continue (And It’s About Time)…”
On June 7, 2022, in a unanimous 5-0 vote, The US Federal Trade Commission reversed a previous 2-2 deadlock vote that will result in the commissions probe of pharmacy benefit managers including the top six PBMs; CVS Caremark, Express Scripts, Inc. OptumRx, Inc., Humana Inc., Prime Therapeutics LLC and MedImpact Healthcare Systems, Inc. After the …
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’ …
Boesen and Snow successfully assisted an independent specialty pharmacy appeal the findings of a major PBMs desktop audit. The preliminary audit consisted of over $1,000,000 in discrepancies, most of which the PBM considered unappealable. Boesen and Snow utilized a multifaceted argument to appeal the “unappealable” claims including a unique presentation of prescription documentation, prescriber statements, …
Pharmacy Benefit Managers (PBMs) are continuing to fight against state regulation. On Tuesday, the Pharmaceutical Care Management Association (PCMA) filed a new brief with the Eighth Circuit Court of Appeals in opposition to North Dakota Century Code sections 16.1 and 16.2. In 2017, the North Dakota passed legislation to regulate PBM practices including limiting the …
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PBM Audits commonly review prescription hard copies, signature/delivery logs, drug invoice purchases, proof of copayment collection, proof of prescriber/patient relationship, patient consent to fill, and non-resident state licensure. PBM Audits are just one of the many hurdles your pharmacy will inevitably face while you strive to serve patients. Poor audit findings lead to extensive financial …