Appeal Tracking...why???

Challenges with PBM Reimbursement Practices

PBMs use multiple methods to apply updated reimbursements, which makes tracking and accountability difficult for pharmacies.
One of the ongoing challenges in the industry is holding PBMs accountable for proper and transparent reimbursement practices.
Common reimbursement methods include:
Lump sums added to EFTs, often without clear labeling
These may appear as “reimbursement,” “adjustment,” or other vague terms
Paper checks, which are still issued in some cases
This is not considered a compliant or legal method of making a pharmacy whole under some state regulations, including Tennessee
These inconsistent and unclear payment methods make it essential for pharmacies to:
Monitor EFTs and 835 files closely
Track appeal outcomes alongside incoming payments
Document discrepancies and escalate when necessary

➤ Tracking Claims

Tracking the outcome of claims and any resulting reimbursement changes is at the discretion of the pharmacy.
Pharmacies may choose to maintain an Excel workbook or other internal systems for tracking.
M.O.M. can provide a blank tracking template upon request to assist with this process.

➤ Pharmacy Reconciliation

Reconciliation is a critical step in confirming accurate reimbursement and ensuring timely payment from PBMs or insurers.
Regular reconciliation helps identify discrepancies, missed payments, or underpayments and supports effective follow-up.

Tracking the progress of MAC appeals and responses is critically important for several reasons:

1. Ensures Accountability

Verifies that appeals are submitted and responded to within required timelines.
Helps identify PBMs that consistently miss deadlines or deny appeals without justification.

2. Supports Pharmacy Reimbursements