Health Law Alliance is publishing this alert to inform pharmacies and providers of a significant enforcement trend that could have serious implications for your business operations. ESI has drastically increased the number of audits it conducts of telehealth relationships, including providers that have contractual relationships with a provider named EZScripts. If you are doing business with EZScripts or other telehealth platforms, you will be subject to increased scrutiny from ESI and other PBMs.

Claim Phishing Audits on the Rise

Telehealth platforms often use pharmacies' National Provider Identifier (NPI) number to run "test" claims, often referred to as benefits eligibility checks.

PBMs and other entities involved in the claims adjudication process, such as McKesson's RelayHealth "switch," typically use "terms and conditions" and other contractual provisions to prohibit these transmissions.

ESI is now attempting to recoup on claims that are associated with these eligibility checks, irrespective that the claims are reversed and not paid. Specifically, ESI is demanding that pharmacies repay the entire amount at issue, meaning the entire dollar value arising from both paid and test claims.

This situation is deeply concerning. ESI is not only reclaiming all reimbursements made to these pharmacies, but also seeking to recover the monetary value of test claims for which pharmacies were never reimbursed, placing the financial stability of numerous pharmacies in jeopardy.

We Defend You Against ESI

If your pharmacy has done business with telehealth platforms such as Noble or EZScripts, and you have received an audit notice from ESI, we strongly urge you to contact us immediately. Our experienced PBM audit attorneys will provide you with a free consultation to discuss your options and provide the legal guidance necessary to protect your pharmacy from potentially devastating financial repercussions. Schedule a free consultation now.