How to Respond to a PBM Audit Notice From An Industry Insider

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Boesen and Snow's, Mark Ziegler, a former PBM auditor, shares tips on responding to a PBM audit notice.

Mark Ziegler, a former PBM auditor, shares tips on responding to a PBM audit notice.

Pharmacies are plagued by the burdens of addressing the terms of their pharmacy benefit manager (PBM) agreements, whether those terms are reasonable or not. Pharmacies are dogged with PBMs wielding their power by initiating a PBM audit – sometimes to root out actual discrepancies, sometimes to injure your business in favor of the PBM’s own affiliated pharmacies. Then, of course, there is the specter of a PBM suspension, in which your PBM might suspend payments and/or threaten termination based on minor, inconsequential claims discrepancies.

In short, PBMs hold all the cards. So, if you run a pharmacy that has recently been hit with a PBM suspension, then it is time to marshal your resources and “kill ‘em with kindness.”

Now, you might think that responding with “kindness” would not make sense. Wouldn’t you want to do just the opposite? Fight back? Take them to court? Quite the contrary, the best, most efficient, most cost-effective way to fight back against a PBM suspension is to address all of their demands without a fuss. In other words, aggressively demonstrate to the PBM that you are more on top of the issues then they are – in a phrase, “kill ‘em with kindness.”

In this article, we are going to discuss five tips on how you can “kill ‘em with kindness” when responding to a PBM suspension. Remember, it is not about giving up, it is about pushing back with evidence to show that you have done nothing wrong. If, after reading this article, you have additional questions about PBM suspensions, we welcome you to contact us at Boesen & Snow LLC. We will fight for you and your healthcare business.

Five Tips on Responding to a PBM Suspension

Be Concise, Clear, and Truthful
First and foremost, in any interaction with the PBM that has initiated a suspension against your pharmacy, you need to be honest and upfront. The stakes are too high to try to hide certain inconvenient matters or obfuscate an issue. Any attempt to get around some alleged claim discrepancy will only result in a more negative perception of you and your pharmacy. Thus, honesty is the best policy.

In that same vein, any interactions with the PBM should be short and to the point. Overexplaining something could hurt more than help. You may confuse an issue further, bring up additional red flags, or make it appear that you are hiding something when you are not. So, when working through a PBM suspension, keep your interactions clear and concise.

Avoid Misstatements or Ambiguous Statements
Consistent with tip #1, make sure that you are accurate and clear when responding to a PBM suspension. It is extremely difficult to unwind a misstatement or vague statement surrounding the issue that caused the suspension.

Moreover, a suspension already puts your pharmacy in a very vulnerable place. Be sure not to exacerbate the problem by giving the PBM information that is not clear or accurate. Again, the notion of “killing ‘em with kindness,” means being upfront and honest about the issue in dispute.

Develop a Corrective Action Plan
Actions speak louder than words. By demonstrating to the PBM that you are initiating a plan or policy to correct the perceived problem, you increase your chances of removing the suspension altogether. Thus, put a corrective action plan in place that shows the PBM that you take the issue seriously, and that you have put mechanisms in place to avoid any problems in the future.

Get an Experienced Attorney in Your Corner
The single best thing that you can do to respond to a PBM suspension is to get a seasoned pharmacy attorney on your side. When you are feeling the pressure and find it hard to be responsive to a PBM that is breathing down your shoulder, having an attorney there to “kill ‘em with kindness” is worth its weight in gold.

Moreover, an attorney with a background in dealing with PBMs will have more insight and be able to employ more tools to help you get out from under the suspension. Thus, getting assistance from an attorney should be something you should strongly consider immediately after getting notice of a PBM suspension.

Consider Working with a Firm that Can Reach Out to Elected Officials
Finally, it is not a bad idea at all to see if your pharmacy can get the help of a law firm that has the ability to reach out to local, state, and federal elected officials. Why? Because PBMs and their strong-arm tactics are increasingly coming under public scrutiny.

Over the last few years, state legislatures have started looking into placing strict regulations around PBMs, precisely because PBMs have been abusing their power over member pharmacies and have even been steering business in a way that only helps their bottom line – with no regard for patient care. Thus, hiring a law firm that is willing to alert public officials to your PBM suspension may very well help level the playing field for your pharmacy.

Conclusion

It may seem counterintuitive, but when faced with a PBM suspension, lean into the information exchange by “killing ‘em with kindness” using the five tips discussed above, rather than trying to stonewall the PBM. You will find that engaging with the PBM and showing that you are on top of the issue could be the most efficient, and most cost-effective way to end the suspension quickly.

Of course, having an experienced pharmacy attorney at your side is crucial. We welcome you to call us at Boesen & Snow LLC, so we can guide you to an effective and efficient suspension response. Call us at 602-900-8562, or contact us online today.

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Allyson Snow
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