Step by step
- Read the letter in full. Note the amount, the claims or period covered, how the PBM intends to collect, and where, how and by when you can dispute it.
- If the letter shows only totals, ask the PBM in writing for the claim list and the reason for each finding.
- Sort the claims into three groups: accept, dispute with records, and needs investigation.
- For each disputed claim, gather the prescription, any documented clarification, proof of receipt and the purchase invoices for the product dispensed.
- Where a finding is about quantities, compare purchases with dispensing at the NDC level, allowing for equivalent products and pack sizes. See what NDC reconciliation is.
- Write the dispute claim by claim, tying each point to an attached document, and send it by the required method. Keep a full copy and proof of delivery.
Questions to ask about the demand
- Which specific claims make up the amount, and what is the reason given for each one?
- Is the amount based on the actual claims reviewed or on an estimate drawn from a sample? If it is an estimate, ask how it was calculated.
- Will the PBM deduct the amount from future payments, and when?
- What further level of appeal is available after this one, if any?
When to get legal help
If the amount is significant, if the demand relies on an estimate from a sample, or if your network participation is at issue, consider speaking with a licensed attorney. State law may also give pharmacies specific rights in PBM audits, and an attorney can tell you whether any apply. Pharma360 provides legal representation through licensed attorneys under a separately scoped engagement. No outcome is guaranteed; the PBM makes the final decision on each claim.
Frequently asked questions
What is a pharmacy recoupment?
A recoupment is a PBM or payer taking back money it paid on claims it considers unsupported, either by asking for payment or by deducting it from future reimbursements.
Can I dispute only part of a recoupment?
Yes. Pharmacies commonly dispute the claims their records support and accept the rest. Follow the instructions in the letter on how to show which claims are disputed.
Will disputing a recoupment reduce the amount?
No result is guaranteed. A dispute gives the PBM evidence to reconsider specific claims, and the outcome depends on the records and the PBM’s review.
How long do I have to dispute a recoupment?
The time allowed is set by the letter and your PBM contract. Check it as soon as the letter arrives and plan your work back from that date.
Official sources
Talk to Pharma360
Facing a recoupment demand? Pharma360 reviews the findings against your records and prepares a claim-by-claim response. See our recoupment & overpayment disputes service, call (267) 809-2396, or request a call back. Your first phone or Zoom consultation is free, one time. Philadelphia-based, serving independent pharmacies in all 50 states.
Published by Pharma360 Solutions LLC · Updated . General information for pharmacy owners, not legal advice. Deadlines and requirements are set by your PBM contract and audit notice; always check the notice.