Audit Issue: Patient or Prescriber Denials of Prescriptions

PAAS National® analysts have seen numerous PBM audit results where pharmacies had recoupments related to patient or prescriber denials of medications. Pharmacies are able to appeal by obtaining signed statements to overturn the denials.

In certain instances, such as investigations, PBMs are reaching out to both patients and prescribers to validate pharmacy claims. Presumably, PBM auditors/investigators are independently collecting evidence to ensure that “the stories match” to determine if pharmacies are acting in good faith. Unfortunately, they typically presume guilt until proven innocent.

Patients may be sent official letters from PBMs asking various questions detailing the interaction with your pharmacy. Here are some common questions that letters may include:

  1. Did you receive the following prescriptions?
  2. Did you authorize the pharmacy to refill the following prescriptions?
  3. Did you pay the copay?
  4. Did the pharmacy offer you a discount on your copay?
  5. How did you receive the following prescriptions (in-person, delivery, mail)?

Some patients may not remember the details of a prescription from years ago, or be scared to answer incorrectly, and decide to not respond. If a patient fails to respond to such a request, this non-response may be deemed a denial, and thus the pharmacy is presumed guilty.

Additionally, PBMs are reaching out to prescribers to determine if prescriptions were authorized to confirm legitimacy. Like patient denials, a non-response from a prescriber’s office paints the pharmacy as guilty (even if you have a date/time stamped electronic prescription – absurd!). Other issues that may come up include prescriber moving practices, retiring or if the pharmacy accidentally billed the claim under the wrong prescriber’s NPI.

If you receive audit results that include recoupments for patient or prescriber denials, consider the tips listed below to help you in your response.

PAAS Tips:

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  • Send audit results to PAAS for assistance in developing an appeal strategy
    • The foundation of an appeal will include signed statements from patients or prescribers to overturn the findings
    • Each PBM has unique requirements for such statements, make sure you understand the fine print
  • It is important to consider documentation already in your possession that can help support your case such as prescriptions or signature logs
  • It is helpful to understand if denials are passive (respondent did not respond) or active (respondent actively denied)
Eric Hartkopf, PharmD