Audit of Optum finds potential legal violations, lower payments to independent pharmacies

A recent audit of healthcare giant Optum, revealed it may have violated Mississippi law, the Northeast Mississippi Daily Journal reported Nov. 8.

Here are 12 things to know about the findings of the audit:

1. The audit uncovered over 75,000 instances wherein Optum-affiliated pharmacies' lowest payments for a prescription drug were higher than at unaffiliated pharmacies, including chain and independent drugstores, over the course of a year.

2. It is illegal in Mississippi for pharmacy benefits managers (PBMs) to reimburse their affiliate pharmacies, or ones they own, at higher rates than nonaffiliate pharmacies for the same services.

3. The audit also revealed that Optum uses 49 different maximum cost lists, 15 of which are used exclusively at independent pharmacies and 22 are used at chain pharmacies. An analysis of the lists showed that independent pharmacies were reimbursed at rates 74% lower than chain pharmacies, on average.

4. A hearing will be held by the Board of Pharmacy on Dec. 18 to address the alleged violations.

5. Optum declined to answer specific questions from the Journal about the audit, but a spokesperson told the publication they identified errors in the audit’s findings and methodology and submitted them to the Mississippi Board of Pharmacy.

6. "The pharmacy—and local pharmacists—play a vital role in supporting people’s health, and we are committed to paying them fairly," Optum spokesperson Isaac Sorenson said. "For pharmacies in rural and underserved communities, Optum Rx is deepening its commitment to support their role by launching new programs, expanding existing initiatives, and launching a new pharmacy network option for customers."

7. Mr. Sorenson also said that the new pharmacy network option will provide pharmacies with increased reimbursements. Generic drug reimbursements will increase by 5%, and name-brand drug reimbursements will increase by 0.2%.

8. The audit reflected some conclusions of an FTC report published in July, which found that large PBMs were paying their affiliated pharmacies significantly more than nonaffiliated ones and set lower rates for independent drugstores and retail pharmacies not owned by a large company or chain.

9. Mississippi Today previously reported that many independent pharmacies in the state feared they may be forced to close due to low reimbursement rates from PBMs.

10. An analysis of a generic drug used to treat bacterial infections showed that an Optum-affiliated pharmacy received a payment eight times higher than that of the lowest-paid independent pharmacy on the same day. Affiliated and chain pharmacies often received payments 20 times higher than independent pharmacies for the same drug.

11. The audit also found that 98% of pharmacy appeals to low reimbursement rates were denied.

12. The audit evaluated Optum for 2022 and was first commissioned by the Mississippi Board of Pharmacy after changes to state law in 2020 gave it more regulatory power over PBMs.

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.

 

Articles We Think You'll Like

 

Featured Whitepapers

Featured Webinars