PBM Suspension

Payment Suspensions: Why Prompt, Accurate, and Complete Audit Responses are Crucial to Maintaining your Pharmacy Cash Flow.

Did you know that your PBM contracts allow for the immediate suspension of your network participation status if the PBM believes you have engaged in or are engaging in any number of possible contract violations? This includes payment withholding, cancellation of outbound checks and possibly the ability to adjudicate claims. PBMs are quick to find fault and implement provider suspensions which can lead to decreased cash flow, excessive amounts withheld, and a lengthy resolution process to receive owed funds or have your provider status reinstated. These types of PBM suspensions are frequently implemented during an audit of claims submitted by your pharmacy and can happen before you have even received a preliminary discrepancy list.

It is crucial for you to respond to all PBM audits in a timely, accurate, and complete fashion. While PBMs provide you with the ability to respond to a preliminary discrepancy report and potentially provide additional documentation to refute discrepancies, preventing these preliminary discrepancies from ever happening will greatly decrease the chance of a suspension, even if the suspension would only be temporary. Boesen and Snow Law can assist you in responding to any type of PBM audit by helping you prepare a complete audit response from the very beginning. This will help protect your provider status from suspension and prevent your cash flow from stopping while minimizing the potential preliminary dollar amount your pharmacy may be liable for. Call Boesen and Snow Law as soon as you receive an audit notification and see how we can guide you to a successful audit response while helping to protect your pharmacy’s bottom line.