Audits pit pharmacists against pharmacy benefit managers

Pills and vitamins

Pharmacists are pushing back against increasingly rigorous pharmacy audits used by pharmacy benefit managers (PBMs) to root out overpayments, eliciting compliants that the audits target expensive drugs and claw back reimbursement over minor infractions, according to the Pittsburgh Post-Gazette.

One Pennsylvania pharmacist, Jay Adzema, says Express Scripts took back more than $55,000 from his independently owned pharmacy following an audit. This included more than $44,000 for anti-seizure medication that he filled over the phone.

“PBMs are running roughshod over whoever they can,” Adzema told the newspaper. “They can justify anything, even charging back $40,000 because the wrong initials are on the paperwork. They are obviously targeting big dollars and care nothing about the healthcare aspects of what they do.”

Adzema’s experience mimics that of many other pharmacists in the state, according to the CEO of the Pennsylvania Pharmacists Association. Adzema and others hold PBMs are denying claims for minor technical errors rather than outright fraud. One Pennsylvania elected official is looking to join 33 other states that have enacted laws surrounding pharmacy audits by pushing a bill that would place certain restrictions on pharmacy audits. 

A spokesperson for Express Scripts told the newspaper the audits are necessary to ensure “the proper prescribing of mediation and reimbursement claims,” which can be an indicator of fraud. She added that Express Scripts returns the overpayments to the insurer or health plan.

Earlier this year, Anthem sued Express Scripts after claiming it was owed $3 billion per year in prescription drug savings. Both the insurer and the PBM are facing a class-action lawsuit that alleges the two companies brokered an agreement that left beneficiaries paying inflated copays

At least one PBM has been on the receiving end of a fraud investigation after federal authorities began digging into contracts between three pharmaceutical companies and an unnamed PBM. But several other PBMs, including UnitedHealth’s OptumRx, are using claims data to cut costs and improve patient care.

- read the Pittsburgh Post-Gazette article