As a pharmacy benefit manager (PBM), Prime Therapeutics regularly conducts invasive audits of participating pharmacies. While these audits are certainly burdensome, they are present a very real risk to pharmacies. If a Prime Therapeutics audit ends unfavorably, the company has a wide range of sanctions it can impose, including withholding payment, instituting prepayment review, and even contract termination. If Prime Therapeutics is your pharmacy’s PBM, it is imperative that you are prepared to defend your pharmacy’s billing practices during the audit process.

Prime Therapeutics auditors are trained to identify even the slightest errors. The discovery of one error often justifies auditors’ aggressive approach, which then leads to increased scrutiny, resulting in a snowball effect. The key to surviving a Prime Therapeutics audit is to enlist the assistance of an experienced pharmacy audit defense attorney as soon as possible.

At Oberheiden, P.C., our Prime Therapeutics pharmacy audit defense lawyers help pharmacies through the PBM audit process. We advise, counsel and represent pharmacies nationwide in all types of OBM audits, including those conducted by Prime Therapeutics. We have centuries of combined experience helping pharmacies protect their interests through the audit process and know what it takes to efficiently wrap up an audit as quickly as possible, minimizing the impact of any potential violations. We recognize that any audit is stressful and presents high-stakes for your pharmacy and livelihood, and we are prepared to do everything we can to ensure a smooth audit.

Pharmacies going through a Prime Therapeutics audit must take an informed, proactive, and strategic approach. Prime Therapeutics’ auditors follow a detailed list of “Pharmacy Audit Recovery Guidelines” and are instructed to recover any payments that appear to be illegitimate. Additionally, auditors will withhold payment for valid claims that are not supported by the proper documentation. This last point is crucial because it means that during a Prime Therapeutics audit, the question is not whether your pharmacy is actually in compliance but whether you can prove that your pharmacy’s billing practices are compliant.

What Violation Are Prime Therapeutics Auditors Looking For?

Prime Therapeutics is generally concerned about whether a pharmacy is engaging in improper billing practices that could result in overpayment from the insurance company. As a result, auditors are provided a list of potential violations to look for, including:

  • Using the incorrect units of measurement;
  • Billing for a brand-name drug, but providing the patient with a generic equivalent;
  • Compounding billing errors;
  • Lack of documentation;
  • Invalid claim authorizations;
  • Duplicate claims;
  • Inappropriate use of a product selection code;
  • Claims manipulation;
  • Ineligible claims submitted through Medicare for reimbursement;
  • Providing patients with incorrect instructions;
  • Pharmacists with invalid or inactive licenses;
  • Providing the patient with too many or too few pills;
  • Lack of specific directions, when required;
  • Dispensing the wrong drug to a patient; and
  • Unauthorized fills.

Of course, this is just a partial list of the possible violations auditors may uncover. Prime Therapeutics designated every error as “may have recovery,” “full recovery,” or “full or partial recovery.” Thus, in the best-case scenario, pharmacies found in violation will need to fight to avoid a recoupment. And, if enough violations are identified, more serious sanctions may be imposed.

When looking for violations, auditors have broad authority to review a wide range of documentation. A few of the possible items that auditors may request include:

  • Books/databases
  • CMS10147 and other required documents and notices
  • Daily prescription logs
  • Fraud, waste, and abuse training logs
  • Internal pharmacy compliance policies and procedures
  • LEIE/EPLS verifications
  • Patient profiles
  • Prescriber information
  • Prescription hardcopies
  • Purchase invoices
  • Refill information
  • Signature/delivery logs

Given the breadth of these investigations, it is common for pharmacies that thought they were in full compliance to experience a less-than-ideal audit. Thus, it is essential that significant effort is made in advance of the audit to understand the process, prepare for the audit, and develop a response plan when the inevitable contingencies arise.

How Pharmacies Can Prepare for a Prime Therapeutics Recovery Audit

As you can see, there are many seemingly insignificant errors that can raise a red flag in auditors’ eyes. As a result, when notified of an upcoming audit, pharmacies must prepare thoroughly. The following list outlines a few of the preparatory measures pharmacies can take in advance of an upcoming Prime Therapeutics audit.

Identify, Locate and Organize All Relevant Records and Documentation

From drug ordering records to electronic prescriptions and refill authorizations, there are many types of documentation that Prime Therapeutics auditors will want to review during a pharmacy audit. Pharmacies must ensure that they have all this documentation on hand. The more organized a pharmacy is in gathering its records, the less time auditors will spend in the building—which is a good thing.

Review Compiled Documentation, Records, and Current Billing Protocol

With the necessary documentation in hand, pharmacies should then conduct an internal audit to determine what issues, if any, are likely to come up during Prime Therapeutics’ audit. If there are, pharmacies should address these issues should by curing any systemic issues that have resulted in repeated or ongoing violations. Additionally, depending on the nature of the discovered violation, there may be additional precautionary measures pharmacies can take in advance of the audit.

Preparing a Defense

Even if your pharmacy is in full compliance, making it through a Prime Therapeutics audit without a retraction requires an effective defense. If there are issues to address, it will be necessary to determine the most appropriate way to approach them during the audit. For example, in some cases, it may be beneficial to disclose known compliance violations at the beginning of an audit; however, on the other hand, pharmacies must be careful not to disclose information that is otherwise not within the auditors’ scope of review and could lead to retractions and other penalties.

Developing an Audit Response Plan

Opening the doors to Prime Therapeutics’ auditors and granting their every request is not an audit response plan. At least not an effective one. In order to mitigate the risk of liability, pharmacies must play an affirmative and proactive role in the process. Thus, management should instruct pharmacy personnel on what to do and what not to do during the audit. Additionally, there should be a designated plan in place for responding to allegations of errors and overbillings.

Collaborating with a Pharmacy Audit Defense Attorney

In order to take develop an effective pharmacy audit response plan, pharmacies should engage audit defense counsel as soon as they learn that they are being audited by Prime Therapeutics. At Oberheiden P.C., our lawyers and pharmacy consultants work with pharmacies and pharmacists-in-charge to develop defense strategies and audit response plans designed to quickly secure favorable outcomes. We will also have a physical presence during the audit to keep an eye on the auditors to make sure they do not exceed the scope of their authority. If your pharmacy is facing a Prime Therapeutics audit, it is important you act quickly so we can get started working together to create an effective plan for your pharmacy to survive the audit.

What to look for in a Prime Therapeutics pharmacy audit lawyer?

Prime Therapeutics audits are not something that all lawyers handle on a regular basis—even those attorneys who frequently represent pharmacies in other related matters. Thus, when it comes to selecting a Prime Therapeutics pharmacy audit defense lawyer, experience is key. Pharmacies should select a lawyer who has successfully handled Prime Therapeutics audits in the past. At Oberheiden, P.C., our pharmacy defense and compliance attorneys have centuries of experience, and many of our lawyers formerly held high-ranking positions in the federal government. In this capacity, our staff members enforced pharmacy regulations, giving Oberheiden, P.C. unique insight into pharmacy compliance obligations and how to effectively navigate a Prime Therapeutics audit.

Frequently Asked Questions:

Why don’t we call ourselves the “best Prime Therapeutics pharmacy audit” lawyers?

 

At Oberheiden, P.C., we are confident in our ability to help pharmacies through a Prime Therapeutics audit. However, we don’t refer to ourselves as the “best Optum RX/Catamaran RX audit defense lawyers.” There are a couple of reasons for this. First, we represent very sophisticated and highly educated clients who will not likely be persuaded by marketing gimmicks or conclusory statements offered without evidentiary backing. Who determines what makes an attorney the “best”? The attorney themselves? If so, then that statement is of little use. Moreover, we feel that the word “best” is subjective and potentially misleading when used to describe an attorney’s services. And, because we take our ethical obligations as lawyers seriously, we refrain from making any misleading statements to the public or potential clients. Regardless, for those looking for the best Prime Therapeutics audit attorney, we encourage you to check out our track record; we believe it speaks for itself.

What is at stake in a Prime Therapeutics audit?

 

Prime Therapeutics audits are intended to ensure that pharmacies are not improperly billing the insurance company. Thus, if violations are uncovered during an audit, Prime Therapeutics may issue a recoupment (withholding money otherwise payable to the pharmacy), begin demanding prepayment review, deny pending claims, or even terminate the contract with the pharmacy. However, if auditors discover anything that leads them to believe a pharmacy is violating state or federal law, Prime Therapeutics may refer the case to the appropriate law enforcement agency. This opens the door to much more severe consequences, such as a federal healthcare fraud lawsuit. As a result, any pharmacy subject to a Prime Therapeutics audit should immediately protect their interests by reaching out to a knowledgeable PBM audit attorney at Oberheiden, P.C.

What are a pharmacy’s rights when undergoing a Prime Therapeutics audit?

 

As a general matter, the relationship between a pharmacy and United HealthCare is defined entirely by the contract. Thus, a pharmacy’s rights during a Prime Therapeutics audit depend on several factors, including the state where the pharmacy operates as well as the terms of the pharmacy’s contract with Prime Therapeutics. This agreement lays out both parties’ rights and obligations and provides for certain processes that must be followed throughout the audit. Generally, pharmacies have the following rights:

  • Prime Therapeutics must provide reasonable notice of the audit;
  • Prime Therapeutics must rely on a limited and clearly defined look-back period;
  • Prime Therapeutics must reimburse a pharmacy for claims that were improperly denied;
  • Prime Therapeutics must provide a pharmacy with timely notice of the audit results; and
  • Prime Therapeutics must provide explanations of any demand for recoupment.

Moreover, a pharmacy also has the legal right to challenge auditors’ findings or any sanctions imposed by Prime Therapeutics. At Oberheiden, P.C., we help pharmacies familiarize themselves with their rights to ensure their interests remain protected throughout the audit process. 


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

If you recently learned of an upcoming Prime Therapeutics 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.