Wilentz Attorneys Successful in Two PBM Audit Appeals

Over the past two weeks, Wilentz Pharmacy Law Attorneys, Angelo Cifaldi and Joseph Carlo, successfully appealed a network termination for a New Jersey pharmacy and reduced audit discrepancies for a New York pharmacy by over 75%.

Network terminations from a Big-3 PBM are potentially crippling to a pharmacy’s viability. More often than not, these terminations result from record-keeping errors or other items unrelated to any fraud, waste, or abuse. In this instance, the pharmacy had a longstanding history of compliance and was terminated over a nominal audit discrepancy. After long discussions and negotiations, and before any litigation or arbitration commenced, Wilentz negotiated with the PBM to rescind the termination and keep the pharmacy in the network.

Audit findings before termination can similarly have a significant impact on a pharmacy’s bottom line. Discrepancies can lead to recoupment or payment suspension, meaning a pharmacy will continue to order and fill prescriptions without payment from a PBM until it recoups the claimed discrepancy amount. In this instance, the alleged discrepancies were significant. Wilentz attorneys leveraged audit regulations to reduce the discrepancies and continue to appeal any remaining discrepancies.

If your pharmacy is facing a network termination or PBM audit, contact Angelo Cifaldi and Joseph Carlo regarding possible legal representation.

Results achieved in prior matters are not meant to be a guarantee of success as the facts and legal circumstances vary from matter to matter.