As a small-pharmacy owner, I am used to government rules and regulations guiding every aspect of my business.
There are standards in place to ensure that prescription medications are dispensed accurately, that patient privacy is protected and that our building is safe and clean.
One area where consistent standards are lacking is in the conduct of audits. Audits conducted by or on behalf of pharmacy benefit managers (PBMs) are not subject to any meaningful regulation; as a result, the PBMs are getting away with practices that are unfair to community pharmacies.
Those of us who operate small pharmacies understand that audits are important to ensure everything is being run above board and no prescription claims are being submitted fraudulently. But they need to be conducted in a way that is respectful and fair to the business being audited.
We are finding the PBM audit process increasingly difficult and arduous to navigate, and they are taking significant time from our top priority patients.
For example, we have had auditors walk in, almost unannounced, on a Monday or Friday, which are our heaviest days for customer traffic. They occupy a desk, and tie up the time of one or two employees for as long as the audit lasts. With fewer staff being available to serve customers, pretty soon the line gets longer and everyone gets frustrated. My wife and I take pride in offering exceptional customer service to local residents, so this situation is unacceptable.
Once we had to open up our offsite storage unit to retrieve some old claims so the auditors could examine them. It took up an entire week and many hours of my staffs time. The auditors did not find anything wrong.
Other pharmacy owners complain that claims are being denied because of small typographical or spelling errors, rather than fraud, at which point the PBM demands a refund for the medication(s) provided to the patient. Additionally, once the clerical error is corrected and the PBM auditor is satisfied, the pharmacy has no way to recoup those dollars.
We definitely feel like the little guy compared to the PBMs, which seem to have limitless staff and resources. State law should be updated with audit standards to be sure small pharmacies are treated fairly by the PBMs.
The Florida Legislature should pass SB 1358, which requires pharmacies be given notice prior to an audit being conducted, and sets a time limit on the age of claims being audited. It also prohibits PBMs from penalizing pharmacies for small clerical errors having nothing to do with fraud. Additionally, it allows pharmacists to appeal unfavorable audit reports to a peer review panel.
On April 3, Sunshine State News reported that Senate Health Policy Committee Chairman Aaron Bean hopes to have a hearing on the bill soon. Community pharmacies -- and their patients -- need this bill. Its enactment will bring fairness to an auditing process that has gotten out of control.
Jim Koivisto owns Hallidays and Koivistos Pharmacy in Jacksonville.
