Pharmacies undergoing a Pharmacy Benefit Manager (PBM) audit are typically prepared to address inventory discrepancies and documentation issues. What many are not prepared for, however, is the increasing use of PBM member denial findings, allegations that a patient claims they did not receive and/or did not authorize the dispensing of a medication for which a claim was submitted. These findings have become one of the most aggressive tools used by PBMs to justify monetary recoupments and pharmacy network termination.
What Are PBM Member Denial Findings
A member denial occurs when a PBM asserts that a patient reported not receiving a prescription or did not authorize a pharmacy to dispense the medication at issue. Major PBMs such as OptumRx, CVS Caremark, and Express Scripts increasingly rely on these allegations during PBM audits.
Unlike traditional audit findings, these claims are often based on unverified patient statements, internal summaries, or undocumented calls, without providing pharmacies access to recordings, transcripts, or any evidence. In many cases, PBMs will treat a patient’s failure to respond to a mailed inquiry as a denial, or interpret an unanswered phone call as a member denial. These practices raise serious concerns regarding the reliability and fairness of such findings.
Why PBM Member Denial Findings Are So Dangerous
PBM member denial audit findings are rarely limited to a single claim. They are frequently used to justify significant recoupments and termination from PBM networks. Because these findings rely on subjective allegations rather than objective records, they are inherently difficult to challenge if not addressed properly from the outset.
More concerning, these allegations are often used as a gateway to broader enforcement actions, including expanded audits and potential allegations of Fraud, Waste, and Abuse (FWA). The rise of member denial findings reflects a broader shift in PBM audit enforcement, where audits are no longer just about documentation, they are about how allegations are framed and whether they are allowed to stand unchallenged.
By the time these findings appear in an audit report, the stakes have already escalated. A misstep in responding can allow unsupported allegations to form the basis for substantial financial liability and operational disruption.
Why Retaining an Experienced PBM Audit Defense Attorney Is Critical
Successfully defending against PBM member denial findings requires more than simply submitting records. Retaining an experienced PBM audit defense attorney is critical, as knowledgeable counsel can identify multiple avenues to dispute and challenge these allegations, including raising legal arguments that PBMs often overlook or ignore.
Importantly, certain state-specific PBM reform laws impose limitations on PBM conduct, including restrictions on improper direct contact with patients in the audit context. These laws can provide powerful defenses when properly leveraged. An experienced attorney understands how to apply these protections, challenge the validity and methodology of the PBM’s findings, and position the response in a manner that protects the pharmacy from escalation.
How Health Law Alliance Can Help
Health Law Alliance has extensive experience defending pharmacies in PBM audits, recoupment disputes, and network termination matters. We understand how PBMs build these cases and how to effectively challenge them.
If your pharmacy is facing a PBM audit, contact us today for a free consultation to protect your business, your reimbursements, and your network status.
