Defending Against PBM Attacks | Payal Amin & Dae Lee, PharmDs & Attorneys at Frier Levitt

Transcript Disclaimer: This transcript is generated using speech-to-text technology and may contain errors or inaccuracies.

Mike Koelzer, Host: [00:00:00] Payal for those who haven't come across you online, introduce yourself and tell our listeners why we're talking today. My 

Dae Lee, PharmD, Atty: name is Layal Amin and I work at a law firm for I Lovet, which is a national boutique law firm. And we focus exclusively on healthcare and life sciences. Um, and we represent a lot of stakeholders across the industry, um, ranging from independent pharmacies to Pharmac.

Payal Amin, PharmD, Atty: Uh, across the nation. Um, I work in a department that represents a lot of the pharmacy owners' interests against pharmacy benefit managers. 

Mike Koelzer, Host: They introduce themselves to our listeners. My name is 

Dae Lee, PharmD, Atty: Dae Lee. I'm a pharmacist attorney from prior Levit. I work alongside a pile. We are in the life sciences pharmacy slash PBM department.

Uh, my main focus is to help pharmacies against PB. These investigations or any adversary reactions taken by PBMs against independent pharmacies. I also, uh, uh, involve myself into the litigation side as well, given my background. And lastly, um, I co-chair. Alongside with our, one of the co-founding partners, John Levitt on our, um, plan sponsor practice group.

How many 

Mike Koelzer, Host: other pharmacist attorneys are there in the 

Payal Amin, PharmD, Atty: firm? So in the firm total, at the moment we have three pharmacist attorneys, um, I'm a practicing pharmacist attorney myself. And, um, I find that this dual role helps to bring a lot of common interest to our, um, client, lawyer relationship. Um, especially being that a lot of our clients.

Pharmacies and pharmacy owners. And I think it helps a lot to bridge the gap. When you're speaking with these clients, as you know, I'm one of you. So it kind of brings a lot of common interest. Um, and you know, it helps to level the playing fields 

Mike Koelzer, Host: a lot. What possessed you to go to pharmacy school and then to law school?

Payal Amin, PharmD, Atty: So for myself, I could say for myself here, I've always had, um, initially I've always, you know, kind of been tuned to the science side of things and helping patients and the patient interaction, working at a retail pharmacy. I saw there's a lot of, uh, regulatory stuff and there's a lot of. Um, other stuff where I can expand myself in compliance and areas of law that overlapped in the pharmacy area that weren't, uh, necessarily addressed in a special area.

So I felt, you know, the healthcare and life sciences was a good background and I always had an interest in kind of addressing a lot of that regulatory aspect of law that overlapped with the pharmacy 

Mike Koelzer, Host: day. How did you end up in law school after? 

Dae Lee, PharmD, Atty: Well, I believe it was during fifth year of Rutgers pharmacy where I took pharmacy law class and, and it intrigued me.

And during my sixth year where I focused on internships or externships and I, I, I heavily, you know, focused on the retail side, but I also was exerting an investment. Where I helped develop, I guess, potential pitches to, uh, uh, investors for biopharma. And there were a lot of, uh, legalese involved with that.

So it intrigued my interests. And then I decided to go to law school right 

Mike Koelzer, Host: away. Good to have you both on this show, were you in class with each. 

Payal Amin, PharmD, Atty: I think we were years apart days a, a year ahead of me in school, but we did go, we did go to the same school. Um, and so his interest started probably at the same time, the fifth year, same professor.

I'm sure that the pharmacy law class was mine as well. So must have been a good 

Mike Koelzer, Host: professor. people that worked for me and say, oh geez, I'm never gonna do what he does. Let's say you're out. Uh, restaurant, which is hard to find these days with all the COVID stuff going on and you're sitting there and someone comes up to you and says, uh, wait a pharmacist, an attorney.

And they'd say, why, why is that needed? What are your stories that you would share with someone to give an example of. Why a pharmacist or a pharmacy is gonna need an attorney. 

Dae Lee, PharmD, Atty: Let me give you 

a punchline. The punchline is vertical integration of payers, PBM and PBM owned pharmacies. They're dominating the industry.

Now, the payers that are affiliated with these pharmacies are also governing the payments that are paid out to the independent pharmacies. so they're dominating the market. They're driving out the independent pharmacies and we hear many, many horror stories about the lack of care coming from the big chain pharmacies and the middleman [00:05:00] being the PBMs who are controlling all these payments.

And they're literally driving out the independent pharmacies at the expense of the. patient so that's why you need someone. You need an attorney who can advocate for independent pharmacies. 

Mike Koelzer, Host: All right, Kyle, what would an example be from you? 

Payal Amin, PharmD, Atty: So, um, it would be similar today's but the one component I would probably, um, focus more on is these PBMs that have these audits.

Left and right, that are being, um, thrown out to these pharmacies and many of these independent pharmacies and pharmacist owners. Um, a lot of them are not aware of all the laws that are there to protect them and various things that they can do to challenge them. Because again, a lot of these. PBM practices, uh, which include these audits that they're allowed to do, um, under their provisions of the manual.

They, um, there's many ways for these pharmacies to challenge them and know their rights, to be able to handle these audits. And a lot of times, um, you know, just. Being in the practice of pharmacy being a clinician. Um, that's not something that you're focused on and there's many things that you're not aware of, but attorneys experienced attorneys like day and I who work on these types of matters every day, uh, can help a lot of these PDM abuses and audits are one of the notable, um, Notorious ways of having these, uh, PBMs come into the pharmacies and do a lot of detrimental, uh, things such as, you know, even eventual these, eventually these audits leading up to termination, and it definitely leads to a lot of harm for these pharmacies, because that is where a lot of these independent pharmacies are going down that path.

And a lot of these, um, the basis of a lot of these are due to, um, PBM abuse practice. 

Mike Koelzer, Host: That are happening 

for our listeners and all the pharmacies know this, but I just wanna describe it this way from listening to two is that we just went through an election here and the US government's supposed to have executive and, um, judicial and, and then what Congress, I guess they would call it.

Right. There's a third word for that. And then you've got, you know, a two party system. And so what you're kind of describing in pharmacy is like those three branches are all run by the same person. And the Congress is the same person and the. The FBI doing the audits is the same person. I mean, it's kind of like this vertical integration that day was talking about.

It's like, I mean, that's got junk written all over it and there's no way to win in that system. It seems well, that's why 

Dae Lee, PharmD, Atty: all the, um, independent pharmacies and pharmacy owners have to fight, you know, they have to continue to fight against these PBM abuse practices, especially the big ones you. The top three PBMs are now controlling what over 80% of the, uh, prescription claims, uh, uh, submitted for the American citizens.

And every day we are, we hear horror stories about, you know, an independent pharmacist that has been in business for over 50 or even a hundred a year going out of business because of PBMs, uh, reduced or because of the reimbursement rate controlled by PBM. Because of the, uh, post point of sale recruitment, whether it be an audit, whether it be a D R fee G E R or whatever effective rate that PBMs come up with, and then recruit at the end of the year, there is no bargaining power for independent pharmacies, and that's why it's, it's extremely important for pharmacies to fight and continue to combat all.

Abuse practices. And that's why you need a real jealous advocate, you know, for independent pharmacies. That's why you need an attorney who knows the ins and outs of the pharmacy law, who knows the, in, who understands the practice of pharmacy day to day operation. You know, that's why you need an. Who could fight for you?

Not just regular attorney down, down 

Mike Koelzer, Host: the street. Okay, Dave, but here's a devil's advocate. You said it yourself, Dave, that these PBMs are so big. You know, there's three main players. They're so big. And I, as a little pharmacy, am so small. So you got David versus Goliath. The other thing you've got is when the day is done.

The pharmacist doesn't have a choice really to get away from these three. So the pharmacist is also concerned about [00:10:00] repercussions of taking legal action against. A PBM and worried about retribution from the PBM to the little pharmacy. It's like, they're so afraid to open your mouth. Do you see that from 

Dae Lee, PharmD, Atty: people I've heard of, but you know, there is certain protection, uh, provided by both federal and state law against retaliation by PBMs.

So Pharmac. You know, they are entitled to dispute claims under the provider manual provider agreement, drafted by PBMs entered into with the independent pharmacies. You know, I, I certainly understand that, you know, uh, David versus Golia. So on that note, it is important that pharmacies come together and join together.

Um, start a grassroot effort such as joining up. Their state ASO pharmacy association, trying to pass a bill. And they're trying to build, trying to have the bill into, uh, uh, uh, enacted into laws, state laws, uh, prohibiting certain actions taken by PBMs. For example, Tennessee is a great example of that grassroots effort.

Uh, recently Tennessee passed a law prohibiting PBMs to recoup fees, uh, that were not readily. Disclose at the point of sale and, and certain states, including Texas have good pharmacy, uh, PBM fair audit laws, you know, all these count, you know, in order for independent pharmacies to survive, besides treating their patient, besides helping their community, they need to come together.

How often 

Mike Koelzer, Host: are you guys acting as basically. A defendant against a claim or something that PBM has aggressively done versus a pharmacy becoming. The aggressor 

Payal Amin, PharmD, Atty: in terms of defense, I think you were asking if, yeah. Are they, uh, are we defending pharmacies ever? Is it 

Mike Koelzer, Host: usually like an audit defense or is it usually Joe from Joe's pharmacy saying I'm sick and tired of being treated this way and I'm gonna make an aggressive pursuit of something in the.

Documents. Right. 

Payal Amin, PharmD, Atty: So there's usually like some sort of cause of action there. So, and it usually stems from an audit and on our, uh, in our area, but there are various other reasons. Um, we've seen pharmacies, um, initiate action without any, you know, PBMs doing anything directly, but it could be related to, like they had mentioned like, you know, DIR fees and GE fees and different things where they're experiencing, um, Mac pricing, like different types of pricing issues that they experience with reimbursement rates that are being offered to these pharmacies.

Based on the contracts that they've entered into. So it could even be, um, pharmacies and this happens more on our litigation side where, uh, pharmacies would wanna initiate a litigation. Um, and typically with PBMs, it's an arbitration process that we go through here. So, um, and that process, um, a lot of the times we are helping these pharmacies initiate something against the PBMs because.

In some way, shape or form having some issue. There's some cause of action. That's leading to it. Um, but it's never, there is something usually specific tied to the basis of them wanting to pursue it. It doesn't always have to stem from an audit, but in the case of an audit, it usually starts with a defense of an audit and it can lead to further actions depending on how far the PBM goes.

Mike Koelzer, Host: All right. So a guy walks down the street and he says, do you wanna sign this? And I say, what is it? And he says, this gives us authorization to kill your dog. And I say, um, boy, I guess I'll sign it. So I signed it. And then a month later, they come and kill my dog. And I say, this is terrible. You killed my dog.

And they say, you sign this. All right. So with PBMs are pharmacists just in the position of being dumb enough to sign an agreement that kills their dog or the PBMs have killed your dog and your cat, or is there something wrong at the very start of the PBMs coming up with a contract to kill your. Are the PBMs just doing what they said they were gonna do?

And, we were dumb enough to sign it. Or is there something illegal about the contracts in the first place? Because it sounds like if you don't have a law against it, it sounds like the best we can do [00:15:00] against the PBMs is to say, well, if you're gonna. Do this at least be gentle. You know, if you're gonna kill my dog, at least put it down gently, you know, I mean, it seems like this has to start through some laws against that vertical integration.

Is that, is that where this has to go? Yeah. 

Dae Lee, PharmD, Atty: I mean, in a way, because the vertical integration already happened. Right, right. Or the top three PBN, the vertical integration is done now. That's why it is important for the pharmacies to start grassroot efforts by introducing bills. That they could stop PBMs from killing their business.

Mike Koelzer, Host: Who cares about 

that? 

Dae Lee, PharmD, Atty: Well, independent pharmacies most care about their business, 

Mike Koelzer, Host: but do 

the people that are setting those laws up, let's say it's a legislature that's making these laws or voting on that. Let's say I run a, you know, a shoe store or something. And I go to the legislature and I say, I don't like how.

You know, Zappos is putting me out of business. Well, I don't know if they care or not. Why does the legislature care about helping out the pharmacists? 

Dae Lee, PharmD, Atty: Well, because helping out the pharmacist means helping out the, uh, local businesses right. And helping out the local communities. And, and, you know, as I mentioned before, there are enough horror stories about lack of care coming from chain Pharmac.

It's because their business model is to set up to run prescriptions as many, any as many prescriptions as possible. Now, along with that government claims like Medicare or Medicaid are paid by the government and are paid by the taxpayers right now out of the vertical integration, it is highly suspicious.

that The PBMs are applying. I'm not saying they're not, I'm just saying they, uh, it is highly suspicious that PBMs are scrutinizing. The affiliated or their own pharmacies with the same degree as they're scrutinizing the independent pharmacies, 

Mike Koelzer, Host: we taxpayers are paying for these services. But if that vertical integration even owns those pharmacies, how much are they gonna scrutinize?

What kind of care is out there? All of us know great pharmacists. In fact, I've never known a pharmacist that decided to go work at a chain because they were an inferior pharmacist. They've gone there, but they've got that structure going all the way up to that integration. That's just pounding these numbers out, going all the way down, even to the pharmacy.

Exactly. Where else do you think that? PBMs overstep their boundaries that a pharmacist can at minimum, just say, no, I'm not doing that. And at maximum say I'm getting my attorney involved because. This ain't right. Where are pharmacists shaking when they shouldn't be shaking? 

Payal Amin, PharmD, Atty: For example, one of the, uh, most recent trends that we've seen here.

Um, and we've just seen recently in the last few weeks that there's been a growing trend among PBMs where, um, PBMs are requesting likes. Onerous member verification documents. Now, if a patient is, you know, going so far as visiting out of town and in a different, um, state altogether, the pharmacy is supposedly only licensed in that state.

For example, let's say Florida, they're only licensed in Florida and you have, you know, many people, you know, senior citizens have multiple homes, you know, they, they visit from different areas. Um, they've gone so far as now requesting documents and taking back money on claims, which were, you know, Paid pursuant to a facially valid prescription and just recouping based on the fact that the member's address is out of state.

And, um, the pharmacy, according to our documents, is something as simple as you're only registered in the state of Florida. Why is this California patient, um, filling here? Are you mailing prescriptions? Um, so they make a lot. Long winded ties. There's no requirement to have anything like this, but they would, you know, in those, yeah.

In that face, you know, of a PBM abuse, um, simple things such as that lead to very detrimental consequences for these pharmacies, they 

Mike Koelzer, Host: know that customer is their customer. You know what I mean? I mean, they know it's their client and let's say you filled, let's say you filled a $500 medicine for. You know, and it's like, all right, this person was in Florida, but you mailed it to Arizona, whatever, you know, or vice versa.

Someone from Arizona got it. Filled there and it's like, Those sons of a bitch. They know that would've been $500, whether that person was in [00:20:00] Arizona or in Florida, they're just trying to not have to pay for it. 

Payal Amin, PharmD, Atty: Right. And they're going after these, you know, egregious ways of trying to recoup monies, um, at the expense and burden of a pharmacy, you know, small, independent pharmacies are not, you know, staff to be doing things like this.

And these requirements aren't even, you know, if we're gonna go strictly by. Provider manual, you know, the contract, you know, things like that are not necessarily put in there. You don't have to go as far as, you know, um, checking all these documents, you know, at the time, if it's a facially valid prescription and a lot of these happen, unfortunately, to like you had mentioned like a 500 or thousand dollars drugs where the reimbursement rates are high.

So they target a lot of these types of prescriptions and you. Find a reason, ultimately for things like this and during audits, they'll, you know, mark these claims as discre it, and then they'll go so far as, you know, taking the money back in advance of even having the full audit, um, being, you know, carried out to its, uh, Termination here, or at least, you know, given the opportunity for the pharmacy to fully address the op um, the audit, um, without that even happening, they're still making recruitments, um, in the early stages and a lot of the laws that are out there, like state laws, it depends on where you're at.

Um, You can be afforded these protections. And it's very simple as, you know, just knowing your rights and the laws and being able to leverage these, uh, to your benefit, being a pharmacy owner, simple things like that. So, 

Mike Koelzer, Host: you know, it used to be that audits were, it seemed to me that audits were more like, let's make sure that you're not stealing from us and let's make sure that you're running a tight enough ship where things don't happen, but they're, they're trying to make money off loopholes.

Right. 

Payal Amin, PharmD, Atty: Yep. That's and that's where these new trends we always see. Um, and various between our various pharmacy clients, we start noticing these new emerging trends, you know, uh, this PBM, it may just be specific to a PBM and then eventually catches on, um, amongst the three big players or, you know, it's maybe focused one PBMs, always focused on this type of, um, audit.

And we have a lot of them. I feel like the experience we get collectively through various pharmacies provides us with, you know, a lot of ammo and how to tackle these issues and how to address these successfully. Um, and in turn, help the pharmacies, you know, keep their business alive and ultimately be able to share, um, the benefits with their greater community and provide the better patient care that we know that they're able to provide.

Um, and more tailored patient care that I see that these community pharmacies, um, So to add to what I was saying previously about, uh, the onerous member, uh, verification documents during these PBM audits that, you know, some of these are fairly simple tactics that these PBMs are using to leverage their power against pharmacies during audits and, uh, requesting onerous types of verification.

Um, Specifically PBMs at this point are attempting to recoup amounts. Uh, the entire reimbursement that eventually, you know, essentially was received already, and it was already paid by these pharmacies successfully. And, um, they'll go by just simply alleging that these members, uh, don't match their addresses.

On their records, although everything had checked out upon reimbursement, um, and it's highly concerning that. Now they're at the tail end of putting this additional burden on our pharmacies to demonstrate that the members did in fact receive their medication despite providing signature logs and things like that.

You know, they wanna go the extra step because a lot of these, uh, audits are tied to audit fees, which PBMs do charge based on the. Of the recruitment. A lot of them are like a set percentage on the recruitment amount. So, um, it can vary from, you know, a few thousand dollars to, to a hundred thousand dollars, depending on how high your, you know, audit discrepancies are.

So it's just, it's never evenly tied in it's, you know, it's very, you know, it's not a flat number. So a lot of this is based on the amount of dollars at subject or at stake here. That's 

Mike Koelzer, Host: ridiculous. It almost seems to me like if someone's really cheating, well, then you kind of throw the book at them and then an audit isn't even good enough.

It almost seems like they should be dropped from. Program, you know, but when someone's not cheating and it's just, they're finding stuff. So what you're saying is that for all the time they spent, they also ha get a fee on top of the, on top of the audit 

Payal Amin, PharmD, Atty: recruitment. Right? So on top of all these claims already being paid for and, uh, reimbursed and you know, they're also.

Getting an additional, you know, an incentive after the completion of the audit. Oh, 

Mike Koelzer, Host: this is probably 20 years ago and we had a. Orphanage a mile from the pharmacy and we would do the medicine for them. I think we would add refills to the same prescription number because the nurses there kind of got in the habit of using the same prescription number, maybe for a few months at a time, it was [00:25:00] just easier on their charts or something like that.

So I had a state inspector from Medicaid come in and I said, Hey, here's what we're doing. We're doing this. The doctor calls us every week. We're just adding prescriptions here. And the guy said, Matt, that's our, don't worry about it. So then, you know, I should have known better than to just take his word.

So then let's say five years later, we get a different inspector comes back and they're saying, well, none of these prescriptions are legitimate. And so I went to the, I drove to Lansing and I went to fight it at this, you know, Peering thing. And, um, I said, how can you guys do this? You know that all of this was on the up and up, you know, you know, the doctor did this, you got affidavits from the nurses, you've got this, you know, we've got a copy of the signature and all that.

We've got a copy of this. And the guy from the state looked at me and he said, well, Mike, if we let you. You know, get away with this, or if we let this happen, how are we gonna get our $20,000 back? And I'm like, you don't get your $20,000 back. The $20,000 went into their stomach. You know, it, it, it medicated them.

That's where that money went. You know, it's like, you don't get it back. Well, there's the state. So they got it back. right. 

Payal Amin, PharmD, Atty: They found a way they found a way it's their patient. 

Mike Koelzer, Host: They're just looking for free money. Yeah. 

Payal Amin, PharmD, Atty: So that's, that's the whole big picture of it, which you kind of just stated right now.

Um, it's the same concept here with, you know, these people have already received them. There was no patient harm in this. There was none of that, you know, and they've received that pursuant to validly, you know, facial leap. You know, pursuant prescriptions here. So, um, 

Mike Koelzer, Host: and the thing about it is these companies, they probably have to show growth all the time.

So first it was just finding crooks and then maybe it was regular audits. And then it was trying to find all these areas where the patient. Got their medicine. And then it's trying to put fees on top of that, but then next year, it's not good enough for them just to do this. They've gotta raise their profits up another, you know, 10%.

So they're gonna find some other ways. Do you see that every year they seem to get more? Outrageous. 

Payal Amin, PharmD, Atty: Yeah. So that's kind of what we just saw recently. Um, and that's why we, you know, we're always monitoring these new trends that are coming out and some of the things are more and more outrageous. And then the trend catches on across the board with different players and ultimately all these trends, you know, if you compile all the trends and the different things that are out there now, there.

20 different ways. Whereas, you know, it was before it was that they only looked at three different ways of, you know, ensuring fraud, waste abuse was not occurring. Now a lot of these, a lot of these are under the guise of, oh, we're doing a fraud waste, um, abuse investigation, but you know, here's 20 different ways that it can lead to it.

And, um, they're not always, uh, what is outlined in the manual. Some of these. Requirements are burdensome. And, um, they go the extra step to kind of, and that's where the law comes in. I feel a lot of times this is where we're able to, and pharmacies may not know these things and just leverage a lot of that back to help pharmacies.

Um, especially when it comes to multiple audits, it could even be one audit inventory. Reconciliation's a big thing that leads to these terminations and, um, it could be small dollars. Dollar amounts, you know, in the few thousands, or it could be, you know, in the millions. Um, and those always, you know, essentially lead to terminations.

And that's the ultimate thing that we wanna kind of more than just the audit we wanna prevent, you know, the dollar amount that they're recouping more than that we're trying to prevent the ultimate termination because that's when these pharmacies face even deeper troubles, it's either period of like a year.

Five years, um, various ways, you know, that they keep them out. And then the readmission process is, you know, burdensome again to have to start all over again. So it seems 

Mike Koelzer, Host: like they wouldn't want to kick somebody out unless they really knew that they were. Trying to be fraudulent because it seems in their best interest to keep the pharmacies there, just so they can screw 'em again.

the next year with their audit, you would think so. , what's in it for them to kick somebody out. 

Payal Amin, PharmD, Atty: So a lot of this is just how, uh, day had mentioned earlier, you know, they're, they're growing, they wanna become the key players and amongst each other, they're trying to, um, you know, obtain the bigger share of the marketplace and obtain all that reimbursement.

Whether, you know, they're able to do it through these audits, you know, under this guy's, they're able to recoup the money, but at a certain point, you know, According to the manual for going to apply it across the board, to all pharmacy [00:30:00] owners, you know, in their interest, they wanna just, you know, take over, get their prescriptions sold to a local.

PBM affiliated change. So that way, you know, that's where their business grows. Ultimately. Cause a lot of these pharmacies end up, you know, when they are terminated or they end up going out of business, not terminated, but if they eventually lead to, you know, the pharmacy closing out of business, they're selling their business somewhere.

Cause you don't leave the prescriptions. Um, just there, you know, you have. Sell the book of our access. It's not 

Mike Koelzer, Host: like you're gonna terminate a little pharmacy and everybody's gonna die. Yeah. They're all gonna take their prescriptions. And the odds are a good percentage of them is gonna go to one of the, the chains, 

Payal Amin, PharmD, Atty: the next town over and the same town over the closest local chain pharmacy that's in the air and the vicinity.

And that's what happens a lot of the time. So. Grows that vertical integration speaks to that again. So 

Mike Koelzer, Host: I should have known that, I guess I did know that of, they want to terminate these smaller guys and. They can't just terminate them for no reason because that's bad press and that's, there's a whole lot of problems there.

I suppose they could 

Payal Amin, PharmD, Atty: legal challenges. There's oh, legal challenges, many states. Do they have any willing provider laws? Um, a lot of states actually, uh, a majority of states. Do have that, you know, as a benefit, you know, so, um, that's a good tool for pharmacies to be able to leverage. Um, and we're able to use that a lot in the admissions process when they're not allowing admission just without a termination and, and many times when they're terminating these pharmacies, um, That's a great tool to have on your side.

And many states have good laws in that regard. So they 

Mike Koelzer, Host: have laws regarding willing providers. Yeah. Any 

Payal Amin, PharmD, Atty: willing provider, you know, but 

Mike Koelzer, Host: when you're terminated, it's like, well, it was their fault. And so we're gonna terminate 'em now. 

Payal Amin, PharmD, Atty: Yeah. That's where we, uh, try to dispute the underlying audit at that point.

And again, there's any willing provider law, so long as they're willing to comply with X, Y, Z, whatever the statute, um, list out, et cetera. We're able to, so they 

Mike Koelzer, Host: can make 'em so onerous to say, well, you've gotta have their birth certificate and we need pictures of you at their five year old birthday party.

Payal Amin, PharmD, Atty: so that's a lot of the things we do with, we help a lot with PBM network access, as well as the post network termination actions for pharmacies has. That requirement in itself, you know, the network access component is very onerous as well. You know, they're, they require a lot of documentation to prove, um, any common ownership things that you're, you know, little things, uh, overlaps in employees.

If you own multiple pharmacies, there's many things that can be overlooked, um, that you may, as a pharmacy owner, may not realize. And many things lead to, um, working on a lot of initial network access where they've just been denied and. Not a lot of these PBMs do have any formal appeals processes. So we're able to usually leverage our contacts with, you know, credentialing team or even the legal team there to try to work through and resolve rather than have the pharmacy wait a period of a year.

Mike Koelzer, Host: By that time, they've lost the customers from a period 

Payal Amin, PharmD, Atty: of a year to five years, depending on the actions of the P of that PBM and the pharmacy. So that's a lot of loss of revenue and, you know, growth for them. 

Mike Koelzer, Host: I tell that to my son who is not a pharmacist, but he's in the business. Mm-hmm , he's like, well, dad, they can't do that.

Just tell, uh, tell that PBM, this or that. It's like the gag clause. Now that let's say, I don't know all the details, but just for sake of argument, let's say that our governmental leaders took out the gag clause that was in there, but let's say it's still in the contracts. And so. I can say you can't throw me out of this contract because the gay clause is not legal anymore.

And they can say, ah, it might be right, but it's gonna take us five years to fight this out. And by that time, yep. You've lost everybody. 

Payal Amin, PharmD, Atty: Right. Right. So, yeah, that's where we come in to try to do a dispute resolution process and, you know, take it any step further. Use the law there to try to leverage a lot of the stuff.

But you need an advocate where I think Dave was mentioned earlier, this is the part where we can assist in doing things like that. Cause at the point of a termination, you're no longer in a contract with them. So there's many different pieces to consider at that point. It 

Mike Koelzer, Host: seems to me, if I'm a PBM. And I'm just trying to get rid of pharmacies.

I might say, oh, Bob's pharmacy is the only pharmacy within 30 miles. So I'm gonna let them be pretty loose and liberal on what they do and say, and how they treat the contract. But Tim's pharmacy, which is a mile away from. One of our own PBM chain stores. I'd like to get them the hell outta here anyways.

And so we're gonna get them for just, you know, one day supply being off or something. Do you see that kind [00:35:00] of decisions? Does it seem to be haphazard ? That's one question two is what are some things that seem not worthy of getting the pharmacy? Pulled out of the network that you've seen, how outrageous has a little infraction been?

Let's say they go 

Payal Amin, PharmD, Atty: as far as minor infractions of a few drugs on an audit, um, that have been short, you know, it doesn't matter the quantity, it, they, you know, it's laid out in their term in their manual there that, you know, this can form the basis. It doesn't have a. Quantity or a dollar amount that pertains to it.

So, um, they can be as, you know, as egregious as they want, or they can be as lax, you know, they've given pharmacy ample time, but they do tend to look at their history of audits or any other things that they have. So if you've been, you know, subjected to a series of audits and they see many various diff discrepant results, um, that can be a component in it.

Uh, many. On your credentialing piece, when you're trying to get in network with the PBM they ask, or even when you are a pharmacy during your credentialing process, cuz every pharmacy still, no matter what, even if you are contracted, you're obligated to update the PBM on any updates and changes, um, as well as you are required to fill out a re-credentialing application and they would require a pharmacy there to, um, answer the question of, have you been terminated from another pharmacy?

So it can be, you know, any. Whether it's laid out in their manual, they can take, oh, okay. You were terminated by X, Y, Z PBM. And where ABC PBM, what was the basis for that? And so then they go after, you know, they wanna know everything about the pharmacy, so they'll take it. The next step, um, to kind of focus on it.

So you think, oh, well, one doesn't talk to the other, but, um, as a part of your re uh, credentialing application, you are, you know, obligated to provide these answers truthfully. And if they ever, you know, find out or things like that, so that's this. Steps that they take to kind of try to get the full picture.

And that's why it's always important. No matter how small your infraction is, you know, you wanna resolve that immediately, provide an explanation, provide some sort of corrective actions, things like that, which we're able to help. Formulate to try to address that underlying, uh, reason or the underlying discrepancy or whether it should even be a discrepancy to begin with.

Um, that's one of the things, so, uh, it's not really like a rhyme or reason that I can say that they, you know, follow a pattern. It can be, um, I've known just personally, I've known pharmacy owners and, um, maybe he's better, like a 10 year pharmacy owner who has never been subjected to an audit and I'm sure.

Various types of claims ranging from, you know, thousands of dollars of claims and, you know, regular, um, or Tova statins in your chronic medications, like less in inexpensive medications, um, and never been subjected to that. So, but once that warm kind of opens, uh, or once they see a response on your credentialing or credentialing application, that's where.

You know, they, they, they try to find something 

Mike Koelzer, Host: Now that you've given me new ideas to think about the worst of a PBM. I'm gonna think the worst of them now, as if I could think any worse of them, knowing that they probably wanna kick people out of the network. And I can't believe that's always the case, but let's just say it was, let's say that their intent on kicking people.

Why did they change that when they saw an attorney come? 

Payal Amin, PharmD, Atty: Well, I think a lot of that is that pharmacies aren't advocating for themselves fully if they're representing themselves and, you know, and I've seen pharmacies come having done their own appeals. And then at the last stages, you know, where they're ultimately at the brink of being kicked out, you know, they wanna save themselves.

And, um, they're, you know, wanting to, you know, retain us and to try to move forward. I think a lot of that has to do. Has to be because of the fact that you're having legal to legal, um, conversations and discussions and leveraging what is contractually valid and what's okay to do. And with the next process, exhausting, all of the dispute resolutions process, the appeals process, which a lot of pharmacies are not aware of.

And I think they know, you know, ultimately if it goes down to litigation, the costs are there. I mean, they have a lot of money. They're. Players in this industry, these little pharmacies may not, but there are many pharmacies who are, who are able to, um, sustain and withhold. Those types of costs. You know, they have that in the know, um, they're able to pursue something.

And if they do see that there is an angle, you know, there is some sort of, um, they're willing to negotiate. If there is something where the laws are on their side, or, you know, an explanation or something of that sort has provided, um, enough reason for them to. You know, engage in discussions. 

Mike Koelzer, Host: What you're saying is they're not necessarily afraid of you because you're an attorney, but you actually bring more.[00:40:00] 

Potential answers and avenues that a pharmacist may not be thinking of. Right. 

Payal Amin, PharmD, Atty: So to, to advocate for themselves a little better here, um, and many times it's the ultimate, you know, the long haul the Casa, and they know that there's things that an avenues that they can resolve without going to that, you know, To that extent of litigation.

You know, when there's chances that we can resolve this many times, some PBMs are open, uh, and receptive to negotiating in advance of it going down that way, um, that pathway, because they'll give opportunities to provide supplemental documentation and things like that, where you may not have gotten that chance.

I mean, you may have, again, it's not to say, you know, a pharmacy couldn't have advocated and gotten that opportunity. Um, but there's many chances that we're able to, you know, leverage another opportunity and provide supplemental, corrective things that, you know, we have seen that, you know, PBMs are receptive to and in wanting to work with the pharmacy at a time, they are, um, it's not to say that you know, that they're not willing to work.

There's many times that we've seen that, but that's where we're able to help. Pharmacies avoid costly litigation or sometimes that does need to become, and we do many times have to escalate to litigation because, um, that's just the way that it went in the course of matters, but that's a lot of where it goes.

Mike Koelzer, Host: Yeah. A lot of pharmacists know. Or they can get their hands on ways to maybe avoid an audit and pharmacists by no means are perfect, but I don't wanna go there. I want to go to two places with you. One. Is, what's a stupid thing a pharmacist could do or say to the auditor or to the PBM after an audit.

That's number one. Number two is what's something a pharmacist can say that's a real zinger. for the auditor. And they wouldn't get in trouble really for saying it, there might not be an answer there, but I know that all of us pharmacists and all the listeners right now, if they're like me, they're like saying what's something I could do to really stop them in their tracks.

Payal Amin, PharmD, Atty: Just to go backwards, I guess, to answer that question. I, I don't know if there's necessarily one specific thing that a pharmacy could do at the. You know, to stop an auditor in new tracks, cuz again, they have to, I feel they do consult a lot with their auditing team as well as you know, when, um, there's legal involved, you know, with their legal.

But I think a lot of the laws, you know, the auditors are not, they're generally just auditors. Um, and some states require the auditors to be, um, and audits to be conducted, um, by a pharmacist to license the pharmacist, depending on that. So things just know your rights as a pharmacy. Could help, especially in the state that you're in.

And it's usually state specific for wherever your pharmacy is. 

Mike Koelzer, Host: Do you think this one will work? Let me try this one out on you. It would go something like this. The auditor asks you a question and I would say to them, do you know who I am? 

Payal Amin, PharmD, Atty: I don't. I do not know if that would work again. That would work. No, I'm not too sure.

So that part, unless they think they're confident 

Mike Koelzer, Host: Do you know who I am? you don't recommend that one? 

Payal Amin, PharmD, Atty: No, I don't. I don't, I don't know how well that would work. 

Mike Koelzer, Host: So now back to the first question, what's a really stupid thing that a pharmacist could do, maybe not right with the auditor, but right in the early parts of that audit.

Yeah. 

Payal Amin, PharmD, Atty: Maybe just, um, Fully engaging in a root cause analysis telling something that the pharmacy has done. And it wasn't a full picture of it. You know, something that egregious the pharmacy did X, Y, Z trying to think of an example off top of my head where a pharmacy would own up to like, oh yeah, we switched the drug without calling the doctor, but we did something simple like that.

But, um, you know, without providing any background explanation, Context to that. Yes. I admit that I did do that and nothing else, you know? Yes, I was wrong, but we won't do it again in the future. Something like that. 

Mike Koelzer, Host: It was a hurricane warning that day and they, and there was, and they evacuated this and the doctor wasn't available and blah, 

Payal Amin, PharmD, Atty: blah, blah.

Yeah. So doing a lot of root cause analysis before you provide your response as something that we would wanna do. So. You know, admitting you did something just because they said, look, you did this. So when you look at your prescription, yes, I did do this, but did you figure out why you did this? Did you have a standing order or something of that sort, um, that would give you the power to do that?

Or is it in your professional judgment that you're able to in an emergency over the weekend, you know, do something where, you know, you're able. Give an emergency days by, and you had, were in a prescription for like a few days to continue something. And, [00:45:00] yeah, that's just an example. I don't know if that's happened, but something like that you would not essentially want to do without thinking about it and identifying your root cause.

Mike Koelzer, Host: Kyle. What's your typical day in terms of, are you on the phone with pharmacists? Are you at their pharmacies? Are you 

Payal Amin, PharmD, Atty: so, um, it depends on the matters that we're currently working on and you have a whole host of clients. Uh, many times the issue may have been resolved with one client, you know, but they kind of remain your client and two months down the line, um, another PBM.

Pursues an audit with them, or they have a different issue with a termination or something of the sort. And a lot of times we do a lot of, um, various matters. It could be a regulatory matter, which will escalate, you know, or, you know, reference to a regulatory side. So, or if it's a litigation thing where they're experiencing different issues, we try to, um, issue a spot and provide them the proper guidance on that.

So, um, yeah, so it could be a client. That's a dormant client, a lot of phone calls happen. So depending on the matter we. Phone calls with pharmacy scheduled or, uh, various communication through emails. So those are zoom calls. A lot of that since we represent all states throughout the United States. So, um, all our clients, whether it's the west coast, we, you know, accommodate them or the east coast depends on where we're at.

Uh, Various phone calls and emails and reviewing documentation pertaining to it and coming up with strategies and, um, kind of like a game plan with them as to how we're going to, uh, resolve this issue, how we're gonna tackle it, you know, working within deadlines, strict deadlines, extensions, uh, various things with those.

You know, responses that we need to gather and anything additional that we may see, you know, on top of just doing the minimum, here's something we recommend doing additionally to, you know, put the favor on your side, at least, you know, and then 

Mike Koelzer, Host: The pharmacies can decide whether they just want an answer or they wanna learn a little bit or change something or whatever.

And you can walk through that with them. 

Payal Amin, PharmD, Atty: Exactly. So, um, there's many times that, you know, when we've, once we've done a root cause analysis, we've identified, okay. Your issue might be hearing your policies and procedures. So many times we will go back and, you know, um, enhance, they may already have one or they may not.

So we go down and, you know, a lot of these PBMs may wanna see that these pharmacies have valid procedures and policies in place. So, um, ultimately addressing. The underlying basis, you know, if you have a formal protocol in place and showing that the pharmacy takes its obligations under the contract and PBM manual seriously, um, and that you adhere to these.

Doing things like that for pharmacies, um, definitely helps. And it's up to the pharmacy. Ultimately we recommend certain steps, you know, um, and what they wanna do and how much they wanna improve. Uh, any chances of, you know, the more things we are able to do. Um, sometimes that gives them a better chance of fighting whatever it is that we're, um, trying to.

So, yeah, 

Mike Koelzer, Host: Kyle, for our listeners that may not know, we talked to your, um, your other half, we're talking with the better half right now. but we talked to your other half Mac, uh, some shows ago. We're not gonna find you guys 10 years from now. If I popped into your town, you guys are gonna be at the same place at the store and you at the law firm, or what do you do?

Payal Amin, PharmD, Atty: That's the plan. Yeah. So we wanna keep him as a pharmacy owner, um, as well. We wanna, uh, keep him as in business, you know, keep him serving the community. Uh, he enjoys a lot of what he does, but again, PBMs are at the heart of all of the issues that have been affecting these independent pharmacy owners. So, um, a lot of the work I do kind of ties into people like him.

So it is kind. It's like a big picture, you know, both of us being pharmacists, but you know, doing different avenues of pharmacy, he works in the retail community and his own being a business owner as well. Um, so I see a lot of the challenges he faces and then find the common ground, you know, with my clients as well.

And as well as the fact that I practice and I see some of these things firsthand and seeing what he experiences. So it helps bring a lot to the table. So, Kyle, 

Mike Koelzer, Host: I don't know if you know this, but Mack told me that if ever I'm out there, I just get to stop by and you guys are gonna feed me. What are you gonna make for me?

What's a special dish that you'd make? 

Payal Amin, PharmD, Atty: I barely cook and, and then I barely cook Indian food. So if I do it's anything really, but Indian food 

Mike Koelzer, Host: I went to a restaurant in town. I think it was Indian food. I'm not sure, but it was the best word I could think of. It was very like perfume, very fragrant, like fragrant.

Is that, does that sound 

Payal Amin, PharmD, Atty: familiar? Yeah, there's a lot of spices, a lot of things going on. So if you were very, if you have a pallet where you're able to. You know, you definitely can identify flavors. I don't know if I'm that great at it. So, you know, I'll, I'll notice things. And after a while, I'll notice, I'm like, oh, there's too much of this in it, but I'm not really max, not that way.

And neither am I, we both weren't really picky about anything except the spices or [00:50:00] my spice level is almost one zero. I'm not really into spices. Um, many Indue people are, I'm not, he can probably tolerate a little more, but not me. I'm just. Pretty bland, not bland. I definitely need flavor, but not the spice, not the heat.

Mike Koelzer, Host: Well, first of all, I'm not gonna. Let Mac take care of our meal planning because when we were at the interview together, he hadn't done his morning prayers yet. And so he wasn't eating till like nine at night. So 

Payal Amin, PharmD, Atty: he's done that on days and I've tried to change it, Kim, I 

Mike Koelzer, Host: ain't doing that with him. And then you and I.

What we'll do is we'll pick up some McDonald's or we can pick up 

Payal Amin, PharmD, Atty: some Indian take outs that you can enjoy enough. Do you think I'd 

Mike Koelzer, Host: have to order it though? Would you know what you were doing at least? Yeah, no. 

Payal Amin, PharmD, Atty: Yeah. That I do. I can, I can probably do it. I just have no interest in cooking Indian food.

You 

Mike Koelzer, Host: could at least 

Payal Amin, PharmD, Atty: order it. Yeah. I could pick it up and I could pick it up. Like in the sense I could pick, take out or I can learn the dishes and I know how to do a few staple. But I'm just not into Indian food enough to like, learn. I have certain dishes I like that are not typical like authentic meals, but, um, yeah, maybe like a pan of money I could do that.

Yeah. I didn't 

Mike Koelzer, Host: I didn't even know what that was. So that's it. 

Payal Amin, PharmD, Atty: Yeah. So it's like a tofu with like a, a Curry sauce, like a orangey Curry sauce and has a lot of flavor packed into it. So, um, it's made a it's like butter. So the money is like butter gravy. It's like a gravy with tofu. I mean, you can make a chicken.

Ma, well, the vegetarian, so yeah, that could be, um, the substitute. So the paneer is like a cheese cube, like tofu, like a block. Okay. That sounds good. And then you just have some non bread and you're usually not making that. That's usually like. Store bought or something. 

Mike Koelzer, Host: So we've got some good friends from Bangladesh.

Do we get to eat Indian food with our hands? Like 

Payal Amin, PharmD, Atty: they do? Yeah. So that would be eaten with a piece of the bread. And you would just take, oh, the bread's like the scoop thing. Yeah. You scoop it and then you dip it in the gravy and you'd have your bites eat it that way. The rice. If you had rice with that, you can just mix the gravy.

So the first part you would just eat it with the bread. And then when you had a leftover gravy, you would just dump your gravy into the rice or vice versa, throw your rice into that bowl and yeah, eat the gravy, like coated with the rice here. 

Mike Koelzer, Host: What of yours and max ancestors. Came to the us. How far back do you go?

Payal Amin, PharmD, Atty: So my mom came here first when she was not married. And she came here from India? Yeah. From India. Yeah, my mom really? Wow. Yeah. Yeah. Just and his parents too. I think his dad might have come in like 1980. Well, he was born here, so I guess did all the 

Mike Koelzer, Host: parents come from. 

Payal Amin, PharmD, Atty: All of her parents were born, they and raiser.

And they came here around the same in the eighties. My pal my mom was here in the earlyish eighties, and his dad maybe came like mid to later eighties, like couple years difference, not too big of a difference, 

Mike Koelzer, Host: But yeah, somewhere, something had been lost because your mom must have fed you. Indian cuisine.

Payal Amin, PharmD, Atty: That's part of the reason I was not I'm not, I grew up on was like every day in elementary school I want, because I'm like, oh, it was a Monday to Friday thing. And I was like, I'm sick of, I'm tired of Indian food. Mac loves it. But even now that I've started. When I do cook, cause I don't cook like Indian food as much right now when he goes he's at his mom's house, like, she's like, oh, well you like this and we're eating dinner.

She goes, oh, but you used to like this, you used to. And I see the face, like she's disappointed in him that he doesn't like. And he knows his wife. Me. I do not. Really prefer Indian food. So that influence he's like, well, he's never known these dishes before his mom cooked for him. So yeah. That's how that's happened.

We've definitely branched out. My sister's like completely no Indian food. I will eat it, but my sister's very like anti just sick of it. Yeah, just so it's like, you've grown up. It's like, you've known too much. Yeah. Like you overdid it when you grew up. And I'm like, I don't want it. I don't have an interest in that.

It's more like Italian, Mexican, Chinese, like yeah. Like all that Oriental food, all that stuff is we'll 

hit 

Mike Koelzer, Host: the Indian place at least. Yeah. We'll definitely do that. And then Matt can stare prayers at. 11:00 PM and could join us later. 

Payal Amin, PharmD, Atty: 1159. It's like I made it. 

Mike Koelzer, Host: Well, Kyle, great. Having you on the show, tell Macau.

Payal Amin, PharmD, Atty: I will definitely let him know. Thank you. Yeah, thanks. Bye-bye bye.