PBM Audits: Letters to Patients for Prescription Verification

Pharmacies often see PBM audit letters requesting documentation to validate paid claims, but not very many see letters sent to their patients.

PBMs have increasingly conducted patient (and prescriber) verifications, in the form of letters sent, to validate claims billed by your pharmacy. These letters are often initiated as part of a PBM investigation where they are searching for fraud, waste, or abuse– if there are inconsistencies between the information provided by the pharmacy, patient, and prescriber this can be a sticky situation.

Letters to patients typically consistent of basic questions like:

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  1. Have you received prescriptions from XYZ pharmacy? If yes, by what method? (in-store pickup, mail, home delivery by pharmacy employee)
  2. Have you been treated by XYZ prescriber? If yes, by what method? (virtual, phone, in-person)

Letters often include an itemized list of claims billed by the pharmacy where the questions may include:

  1. Did you request the pharmacy to fill this prescription?
  2. Did you receive this prescription?
  3. Did you pay the copay amount listed?

Patients may fail to respond to these letters for a variety of reasons, including: not recognizing the PBM name (and afraid of a scam), not remembering the details (and are afraid to answer incorrectly) or not being able to respond (e.g., literacy issues or changes in address).

PAAS National® has received audits where PBMs will issue audit results to the pharmacy that include recoupments for patient denials of receipt or paying copay where the pharmacy has never been asked to provide signature logs or proof of copay collection – these unfair conclusions are drawn before the pharmacy has had a chance to provide objective evidence to defend themselves.

PAAS Tips:

  • If your patients are in receipt of a PBM letter, encourage them to respond
    • PBMs have been known to interpret a non-response as a “denial”
  • Providing copies of the original documentation may be enough to overturn the findings; however, certain situations dictate signed affidavits
  • See our April 2022 Newsline article, Prescriber Denial of Prior Authorization Can Lead to Recoupment for additional insight on letters to prescribers
Eric Hartkopf, PharmD