Dentaquest PBM Audit

Renowned Pharmacy Defense Lawyers Protecting the Rights of Practitioners Nationwide

At the healthcare defense firm of Oberheiden, P.C., we maintain an active PBM audit practice. Our team has centuries of combined experience skillfully representing pharmacies in audits conducted by Pharmacy Benefit Manager audits. We are often called upon to protect the rights and interests of pharmacists and pharmacy owners through this complex process. Several of our senior attorneys previously worked in high-ranking positions with various federal government entities, including the Health and Human Services Office of Inspector General and the Drug Enforcement Administration. This gives the pharmacy audit lawyers at Oberheiden, P.C. an advanced level of knowledge and experience that we put into every case we handle. Regardless of whether your audit is scheduled for a month away or tomorrow, our Dentaquest PBM audit lawyers are available to intervene in the process immediately.

What Is Dentaquest?

Dentaquest is a pharmacy benefit manager that specializes in administering oral healthcare plans. The company manages dental benefits for over 30 million people, working with more than 80 oral healthcare centers across six states.

As a PBM, Dentaquest regularly conducts burdensome audits of participating pharmacies. These audits remove a pharmacist’s focus from running their business and may result in significant consequences if auditors identify any compliance issues.

If Dentaquest is your PBM and you recently learned that you will be subject to a PBM audit in the near future, it is imperative that you contact an experienced pharmacy audit defense law firm for immediate assistance. Any PBM audit, including Dentaquest audits, present very high stakes. Yet, most pharmacies are unfamiliar with the rights they have throughout the audit process. An experienced Dentaquest PBM lawyer can help pharmacies navigate the process, increasing the likelihood of a favorable audit.

What Is Involved in a Dentaquest PBM Audit?

Dentaquest is a Pharmacy Benefits Manager, which means the company essentially acts as the intermediary between the pharmacy and the insurance company. Years ago, insurance companies used to administer their own prescription drug plans; however, over time, it became too burdensome. Thus, now it is common for insurance companies to outsource the administration of their prescription drug plans to a PBM.

Some of the aspects of a prescription drug plan that a PBM may handle include:

• Developing and maintaining lists of covered medications;
• Using their bulk purchasing power to negotiate rebates and discounts from drug manufacturers; and
• Contracting directly with pharmacies to reimburse the pharmacy for drugs dispensed to patients.

Of course, Dentaquest makes a handsome profit for its role in the process. Typically, when a pharmacy fills a prescription under the insurance plan, the insurance company reimburses the PBM rather than the pharmacy. It is then up to the PBM to reimburse the pharmacists.

Here is where it can get tricky for pharmacists: The PBM contract between the pharmacy and Dentaquest allows for Dentaquest to conduct audits of the. The stated purpose for a PBM audit is to ensure that the pharmacy’s billing practices are in compliance and that they are not overbilling the insurance company. When Dentaquest initiates an audit of a pharmacy, it’s referred to as a PBM audit.

However, PBM audits are not subject to federal laws, leaving all regulation up to the states. And, of course, states have varying laws governing these companies. The result is that, in many states, Dentaquest and other PBMs operate under a veil of secrecy, putting much of the PBM audit process behind closed doors. However, based on publicly available information related to previous audits, PBM audits typically target the following types of violations, most of which stem from billing mistakes and the requirement that a pharmacy maintains comprehensive records:

• Accepting prescriptions written by excluded providers;
• Billing for unapproved drugs;
• Compound drug billing;
• Failure to create or maintain records;
• Falsification of records;
• Filling illegitimate prescriptions;
• Intentional and unintentional billing and coding errors;
• Invoice shortages;
• Licensing violations;
• PBM contract fraud; and
• Telemedicine violations.

Given the lack of information about the audit process and the power conferred upon PBM auditors, they often conduct themselves as though they are federal Medicare fraud agents. However, that is not the case; they are employees of a privately-owned company. That said, Dentaquest auditors have significant power to disrupt a pharmacy’s business operations in the event of an unfavorable audit.

What Is at Stake in a PBM Audit?

The purpose of a Dentaquest audit is to ensure that pharmacies have not improperly billed the insurance company. If auditors discover significant violations, Dentaquest may seek a variety of sanctions against a pharmacy. For example, Dentaquest may demand a recoupment or could even terminate its contract with the pharmacy. Additionally, auditors could refer a case to state or federal law enforcement agencies if they discover evidence of what they believe to be healthcare fraud. Given this reality, the stakes of a Dentaquest audit are very high, and any pharmacy subject to a PBM audit should not delay in protecting their interests by reaching out to a knowledgeable PBM audit attorney.

What You Need to Know About a Dentaquest Audit

Dealing with a pharmacy benefit manager such as Dentaquest is an unavoidable reality for most small and independent pharmacies. And while pharmacists must command a certain knowledge of the regulatory environment in which they operate, many pharmacies are unfamiliar with the PBM audit process as it is very different from other types of healthcare fraud audits. However, given the high stake in a PBM audit, it is essential that pharmacies understand the basics of a PBM audit.

PBM Auditors Have a Contractual Right to Audit Your Pharmacy

When you began your relationship with Dentaquest, you signed a contract. In this contract is a provision that grants Dentaquest to conduct audits of your pharmacy. Thus, by refusing Dentaquest auditors access to your records or by otherwise preventing an audit, you may be found in violation of the PBM contract.

Auditors Do Not Have Unlimited Access to All Your Records

While PBM audits cannot usually be entirely avoided, that doesn’t mean that they are not limited in scope. Certainly, auditors can request to review certain documentation, and most auditors’ requests are within the bounds of their authority. However, requests that fall outside the scope of the PBM contract do not need to be honored. Of course, determining what is covered in a PBM contract and which documentation and records a PBM auditor is entitled to review is not always straightforward and requires a nuanced reading of the entire PBM contract. An experienced PBM audit defense attorney can help prevent auditors from going on fishing expeditions by presenting them with factual or legal reasons why their requests exceed their authority.

Pharmacies Are Not Without Rights During a Dentaquest Audit

PBM contracts are governed by contract law, which varies significantly by state. Additionally, every PBM contract is slightly different. However, as a general rule, pharmacies enjoy at least the following rights during the PBM audit process:

• The right to a clear explanation for any demand for recoupment;
• The right to a limited and clearly defined look-back period;
• The right to reasonable notice of the audit;
• The right to receive timely notice of the results of the audit; and
• The right to reimbursement for improperly denied claims.

PBM Auditors’ Findings Can Be Challenged

Every pharmacy has the same goal during a PBM audit: to make it through the process without any violations. However, given auditors’ incentive to uncover anything that looks like a potential violation, many PBM audits end with a finding of at least some type of violation. When this occurs, PBM auditors will present their findings and demands as a matter of fact. What they won’t tell you is that you can negotiate with the PBM company, either to remove certain violations or to reduce the proposed sanctions. In the event that Dentaquest is unwilling to engage in fair negotiations, a Dentaquest PBM audit lawyer can pursue legal action, for example, by seeking an injunction or other relief.

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Schedule a Free No-Obligation Consultation with a Dentaquest PBM Audit Attorney at Oberheiden, P.C. Today

If you recently learned of an upcoming Dentaquest audit, it is imperative that you protect your interests by reaching out to the knowledgeable PBM audit attorneys at Oberheiden, P.C. With centuries of experience defending and counseling pharmacies in all types of enforcement and compliance matters, we have the knowledge, abilities and resources to effectively resolve a PBM audit as quickly and favorably as possible. You can reach the firm by calling 888-680-1745 to schedule an appointment. You can also complete our online contact form, and one of our lawyers will reach out to you shortly.