PBM Success Stories

Boesen & Snow Claws Back $1.1M from Closed PBM Audit for Specialty Pharmacy Client.

Boesen & Snow successfully assisted an independent pharmacy client appeal the final findings of a major PBM’s desktop audit. The final audit findings consisted of approximately $1.2M in recoupment, primarily due to drug invoice shortages. The PBM refused to accept drug inventory transfers from a commonly owned pharmacy stating that the transferring pharmacy did not purchase enough inventory to both transfer product and service its own members. Boesen & Snow sliced through this PBM tactic by presenting evidence of inventory purchases and complete dispensing reports for a two-year period at both pharmacy locations, showing that no invoice shortages existed. Ultimately, over two years after the initial audit appeal, the PBM agreed with the final appeal and began the financial process of returning approximately $1.1M of recouped funds to the pharmacy.

Boesen & Snow Forces PBM to Correct Audit Mistakes and Recovers $12.5M of Recouped Funds.

Boesen & Snow successfully negotiated an expedited preliminary audit review after a major PBM incorrectly determined that approximately $12.5M in invoice shortages existed for five commonly owned pharmacies and imposed a devastating payment suspension. The PBM disregarded purchase invoice documentation from major wholesalers. Boesen & Snow intervened and leveraged its relationship with the state Department of Insurance to secure an expedited review within the PBM that resulted in a 66% decrease of initial audit findings. Boesen & Snow continued to argue, however, and it partnered with its client to present a robust final audit response that reduced the findings by 96%. The firm’s Washington DC lobbyist continues working with elected representatives form the pharmacies’ home state to address the PBM’s monumental errors and to educate state Departments of Insurance regarding enforcement of historically disregarded PBM audit regulations.

Boesen and Snow Successfully Fights to Force PBM to Return over $1M from “Unappealable” Audit Findings.

Boesen & Snow successfully assisted an independent pharmacy client appeal the findings of a major PBMs desktop audit. The preliminary audit findings consisted of approximately $1,034,000.00 in discrepancies, most of which the PBM considered unappealable. Boesen & Snow successfully argued applicable state audit law and provided worked with its client to provide prescriber statements and other documentation to refute the final findings. Ultimately, the PBM agreed with the appeal and credited approximately $1M of discrepant claims.

Boesen & Snow Helps Pharmacy Dispute PSAO General Effective Rate True-Up.

Boesen & Snow was able to contest an independent pharmacy client’s Generic Effective Rate Reimbursement true-up by their PSAO on behalf of a major PBM. After reviewing the specifics of the true-up, Boesen & Snow discovered discrepancies in the PSAO’s data that had been used to determine the amount of the claw back. After further review, the client pharmacy received a payment of approximately $330,000.00.

Boesen & Snow Fights to Have PBM Consider Pre-Audit Period Purchases.

Boesen & Snow successfully assisted an independent pharmacy client appeal the findings of a major PBM’s invoice audit. Boesen & Snow analyzed the dispensing data and argued that purchase invoices from nearly 10 months before the audit period were in fact substantial and valid for the amounts of medication dispensed during the audit period. Ultimately, the PBM agreed with the appeal and credited over $54,000 of discrepant claims.

Boesen & Snow Uses PBM Provider Manual Against PBM to Eliminate Reportable Discrepancies.

Boesen & Snow assisted an independent pharmacy client appeal a major PBMs preliminary audit finding and prevent the PBM from reporting the matter to local law enforcement and regulatory agencies. The PBM’s findings included failure to provide proof of business-to-business financial transactions substantiating drug inventory purchases. During the audit, the PBM threatened reporting the pharmacy client to law enforcement and government regulatory agencies. Boesen & Snow successfully provided appeal arguments that proved the relevant Provider Manual provision was not enforceable and the PBM ultimately accepted the pharmacy’s documentation and eliminated the reportable discrepancy types.

Boesen & Snow Avoids Network Termination for Pharmacy Client.

Boesen & Snow negotiated a corrective action plan on behalf of an independent pharmacy client in response to a major PBMs audit. The audit findings included the noncompliant application of manufacturer coupons and drug invoice shortages. Boesen & Snow assisted the client in providing updated Co-Pay Collection, Inventory Management, Claims Submission, and Compliance Program Policies and Procedures that the PBM accepted as appropriate corrective actions by the PBM in lieu of network termination.

2. PBM Termination Disputes/Arbitration

Boesen & Snow Secures Another Reversal of PBM Network Termination for 50-State Pharmacy for Member Denials.

Boesen & Snow recently secured the reversal of a major PBM’s decision to terminate a pharmacy from its network. Before the reversal, the PBM had rejected the pharmacy’s documentation refuting the audit findings and had quickly issued its termination letter. Boesen & Snow collaborated with the pharmacy client to obtain and provide overwhelming evidence to refute and overturn the “Member Denials,” which were the basis for the PBM’s decision to terminate. The pharmacy operates in all 50 states and had armed itself with processes that produced documentation of its compliance with the PBM’s provider manual. Upon the successful presentation of the evidence and legal arguments to the PBM’s Appeal Hearing Committee, the PBM promptly rescinded the termination decision on a conditional basis. Boesen & Snow continues to advise and guide the pharmacy client to meet the conditions of the rescinded termination.

Boesen & Snow Secures Another Reversal of PBM Network Termination for 50-State Pharmacy for Invoice Shortages After Store-to-Store Transfers.

Boesen & Snow recently secured the reversal of a major PBM’s decision to terminate a pharmacy from its network. Before the reversal, the PBM had rejected the pharmacy’s inventory transfer documentation refuting the audit findings and had quickly issued its termination letter. Boesen & Snow collaborated with the pharmacy client with the implementation of an operational strategy and corrective actions to alleviate the PBM’s concerns leading to the termination. Upon the successful presentation of the corrective actions to the PBM’s audit team, the PBM cancelled the appeal hearing, rescinded the termination, and the pharmacy was reinstated.

Boesen & Snow Secures Reversal of PBM Network Termination.

Boesen & Snow Secures Reversal of PBM Network Termination for False Common-Ownership Concerns.

Boesen & Snow successfully assisted an independent pharmacy client appeal a major PBM’s decision to terminate pharmacy from its networks due to “common control with a previously terminated pharmacy.” Boesen & Snow successfully presented refuting evidence to the allegation of common ownership to the PBM’s internal legal counsel, delaying the termination date and opening good faith negotiations. Boesen & Snow was able to negotiate a settlement with the PBM allowing the pharmacy client to remain in network under the condition of increased audit oversight. Ultimately, Boesen & Snow was able to negotiate the terms of the increased oversight and the pharmacy client retained its status as a Provider in the PBMs network.

3. PBM Enrollment & Network Status Issues

Boesen & Snow Leverages Any Willing Provider Laws to Reopen Enrollment Application.

Boesen & Snow successfully negotiated the reopening of a small independent pharmacy client’s enrollment application after the major PBM denied the initial application due to the PBM’s requirement for secondary accreditation. Boesen & Snow invoked applicable state and federal any willing provider laws as well as the independent pharmacy client’s current accreditations when appealing the denial. Boesen & Snow continues to advise and guide the independent pharmacy client through the ongoing reopened enrollment process. Boesen & Snow Helps Pharmacy Remain in Network During Sale Despite DEA Permit Surrender.

Boesen & Snow represented the Seller of an independent pharmacy who had voluntarily surrendered their DEA permit prior to the transaction being finalized, putting the transaction at risk due to the threat of the pharmacy being terminated from PBM networks. Boesen & Snow was able to negotiate with several major PBMs to keep the pharmacy in their networks, despite the lack of a current DEA permit, pending conclusion of the transaction.

Boesen & Snow Leverages State Representatives to Help Pharmacy Gain Network Enrollment.

Boesen & Snow has successfully lobbied on behalf of a small independent pharmacy denied enrollment into a major PBM’s network. Boesen & Snow lobbied Local state representatives on behalf of the client pharmacy, securing letters of support for the pharmacy to the PBM. The letters assisted in bringing the PBM back to the negotiating table and allowed the client pharmacy the chance to correct errors in its initial enrollment application. Boesen & Snow guided the client pharmacy through the re application process and successfully negotiated the client pharmacy’s enrollment.

Boesen & Snow Successfully Appeals Network Enrollment Denial for Retail Pharmacy.

Boesen & Snow successfully appealed a major PBM network enrollment denial due to a small, retail pharmacy having formerly employed a pharmacist-in-charge who, unbeknownst the client, had worked at another pharmacy with significant audit findings. The firm helped identify the former employee and presented a timeline and regulatory filings to the PBM to demonstrate that the employee had left the pharmacy before the enrollment denial. The firm worked with the client to document its due diligence with its current pharmacy staff and ultimately the PBM reversed its decision. Boesen & Snow has continued to help shepherd the pharmacy through the remaining application processes.

Boesen & Snow Successfully Appeals Network Enrollment Denial Due to Previous Audit Findings.

Boesen & Snow helped a current client successfully appeal a major PBM network enrollment denial resulting from audit findings. The firm had previously helped the pharmacy avoid termination at a commonly-owned location due to audit findings regarding purchases from unauthorized trading partners. Despite not terminating the one pharmacy, the PBM later denied enrollment to a new pharmacy that the client had purchased. Boesen & Snow had worked with the client to implement corrective actions from the audit, and was able to leverage compliant purchases after the audit to demonstrate to the PBM that there was no basis for ongoing concern. The firm continues to assist the client to shepherd it through the remaining application processes.

4. Political Advocacy

Boesen & Snow assisted a state pharmacy association in drafting, revision and submission of language included in a Senate Bill amending the state’s Revised Statutes, specifically related to PBM oversight and the prohibition of specific PBM fees. The Senate Bill was ultimately passed, including language submitted by Boesen & Snow, and signed into law by the governor.In addition to the firm’s DC lobbyist, the firm is working with numerous Departments of Insurance to educate them on PBM abuses as they develop their enforcement positions and may be able to impose sanctions or fines on a PBM related to audit abuses.

5. Board of Pharmacy Defense Related to PBM Complaints

Boesen & Snow routinely defends independent pharmacy clients under investigation by a State Board of Pharmacy due to a complaint from a major PBM regarding audit findings. Boesen & Snow assists in defense of the complaint, providing the appropriate documentation and refuting any arguments that a violation of law has occurred.