What Are My Rights During a PBM Pharmacy Audit?

 Posted on August 27,2024 in PBM Pharmacy Audits

Pharmacy benefit managers (PBMs) are companies that act as middlemen between pharmacies and health plans or insurers. Originally created in the 1960s to process insurance claims, PBMs have grown in power and serve several functions, one of which is setting the prices for prescriptive medications. PBMs do this by negotiating drug prices with insurance companies. When a pharmacy fulfills a prescription, it sends the claim to the PBM, which charges the insurer the negotiated price. The PBM then reimburses the pharmacy for the medication while pocketing some of the cost.

Although PBMs have become controversial, they remain a reality in the pharmaceutical industry.

PMBs occasionally conduct audits of pharmacies. A pharmacy may be randomly selected, or a complaint or discrepancy may trigger the audit. Either way, it can be a difficult and costly ordeal. Because PBMs wield a lot of power, it is important to know your legal rights if you are audited. This article will discuss what a PBM audit is, your legal rights, and how to contact an Illinois PBM audit attorney who will protect you.

What Is a PBM Audit?

The purpose of a PBM audit is to make sure the PBM or insurance company has not been overpaying the pharmacy for the drugs that were dispensed. During the investigation, the PBM matches the claims with the pharmacy’s prescriptions and looks for ways to claw back as much money as possible. For example, if the PBM paid the pharmacy for dispensing a certain drug but finds the pharmacy dispensed a cheaper, generic version of the drug, the PBM may try to reclaim the difference in cost.

Audits are often profitable for PBMs but costly for pharmacies, who need to defend their dispensations. Data show that in 2020, the average audit cost pharmacies $23,978.

What Are My Rights in a PBM Audit?

Illinois law provides certain protections to pharmacies during PBM audits. For example:

• A PBM cannot audit more than 100 prescriptions at a time and no more than 200 prescriptions in a 12-month period.
• A PBM cannot audit a pharmacy more than once every six months.
• A PBM has 24 months from the date a claim was submitted to audit the claim.
• A pharmacy has the right to appeal the PBM’s finding, and the PBM cannot claim penalties from the pharmacy until after the appeal deadline.
• A PBM cannot claw back dispensing fees, which pharmacists charge to cover the costs of storing medications. This can only be done in certain cases, like if the prescription is invalid or the medication was not delivered to the patient.

Contact an Illinois PBM Pharmacy Audit Attorney

If you are facing a PBM audit, it is critical to have strong legal representation. Attorney Jay Bogdan is not only an experienced Illinois PBM pharmacy audit lawyer but is also a licensed pharmacist. Schedule a free consultation with The Law Offices of Joseph J. Bogdan, Inc. by calling 630-310-1267 today.