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Tallahassee Democrat: Bill Mincy: Fair audits help small pharmacies – and patients

Wednesday, April 24, 2013

A level playing field is crucial to the success of any small business. This session, the Florida Legislature should take the opportunity to even out what has become a lopsided relationship between independent pharmacies and corporate pharmacy benefit managers (PBMs).

Enacting the language contained in House Bill 791 or its companion legislation, Senate Bill 1358, would revamp a pharmacy audit process that currently rewards large corporate PBMs while punishing small pharmacies. Similar legislation has been introduced and passed in over two dozen other states, suggesting pharmacy audit abuse is a widespread problem. Additionally, this legislation would extend uniformity to include the same process to the commercial marketplace with what already takes place during Medicaid audits.

All Florida pharmacies are audited to guard against fraud, waste and abuse in claims processing. That is the legitimate role of PBMs. Patients and taxpayers need to know their health dollars are being spent wisely and cheaters are being caught. Nothing in this legislation would prevent PBMs from fulfilling this role.

But the PBMs have adopted heavy-handed techniques that go far beyond finding fraud. I run a firm (PPSC) that serves the business needs of independent pharmacists. Our clients tell us they struggle to comply with audit standards that vary from one PBM company to the next. The PBMs are able to set their own rules and rig the system to benefit their own companies, because there are no state-established guidelines for their behavior.

Here are just a few examples of the complaints I have heard: Auditors do not schedule meetings in advance and simply show up; auditors are often not Florida-licensed pharmacists; pharmacists often wait months to find out the results of an audit; and, these pharmacists have no way to appeal adverse findings.

The PBMs also penalize pharmacies for unintentional processing errors on the part of pharmacy staff such as typographical errors and misspelled words. After finding this type of mistake, PBMs profit by charging a pharmacy for the full cost of a claim, even though no fraud occurred.

While these practices are unfair to all community pharmacies, the audit process is especially difficult for Florida’s 1,200-plus independent pharmacies, because they tend to be smaller and have fewer staff. These independently owned pharmacies can be found on street corners in small towns and large urban centers alike. Pharmacists are a critical part of the health provider network in every community, and their time should be spent serving patients, not on trying to comply with an audit process gone amok.

State law should spell out how audits are to be conducted, and the rights and responsibilities of each party. House Bill 791 and Senate Bill 1358 would set strong standards for all pharmacy audits. Pharmacies would be given at least a week’s notice before an audit. Audits would only be conducted by licensed pharmacists and audit reports would be delivered within 90 days of the audit. Pharmacists would be given the time and ability to question and appeal audit findings. And, pharmacies would no longer be punished — and PBMs rewarded — for things like misspellings.

Small pharmacies are not asking for any special treatment when it comes to audits of their business, only fairness. Passage of this legislation would make the changes needed to restore integrity to the audit process.

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