Facing Potential Disciplinary Action? PBMs Require Notification!

It can be a very stressful time for a pharmacy when they, or an employee, are being investigated by a regulatory body (e.g., Board of Pharmacy, Office of Inspector General (OIG) or Drug Enforcement Agency). It will likely not be the first thing on your mind to notify contracted PBMs. Consider

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

paraphrased language from the OptumRx Provider Manual:

  • OptumRx is partnered with NCPDP for credentialing—all pharmacies are required to maintain Part 1 and Part 2 of their profile with NCPDP
    • Credentialing documentation must be provided within 48 hours if requested
    • Re-credentialing occurs every 3 years
  • OptumRx must be notified within 7 days, in writing, and include information regarding the agency who is conducting the investigation, if:
    • The Pharmacy Providers license/permit is in jeopardy of being suspended or revoked
    • The Pharmacy Provider receives notice of any proceedings which may lead to disciplinary action
    • Any disciplinary action is taken against the Pharmacy Provider or employees, including but not limited action taken by a Board of Pharmacy, OIG, GSA, law enforcement or other regulatory body
    • There is a subpoena of records related to Covered Prescription Services or the Pharmacy Providers business conduct
    • Seizure by law enforcement of the Pharmacy Providers prescription records, computer systems, financial records, accounts, or real property
  • Failure to report to OptumRx can result in immediate termination or suspension from the network

It’s important to note that OptumRx is requiring notification even if no disciplinary action was taken against the pharmacy or the employee. Every PBM may have different requirements, but the major PBMs require some sort of notification. Be sure to review a copy of the Provider Manual if you are unaware of the regulations regarding this issue.

These situations often arise after re-credentialing as PBMs are reviewing the credentials of pharmacy employees. PAAS National® has successfully assisted pharmacies facing Network Termination due to a failure to notify. Notify PAAS right away if you’ve received a Letter of Warning (Contract Violation) leading to a breach of the Provider Agreement.