PBMs often flag telehealth claims and scrutinize the legitimacy of such scripts. When we see chargebacks based on “Invalid patient/prescriber relationship,” we know that it’s time for some legwork. We typically research (1) where the prescriber and patient were located; (2) whether prescriber was authorized to prescribe the medication in question; and (3) whether the prescriber established valid relationship with the patient. It usually takes time and resources to reach out to the prescribers and obtain their statements and/or evaluation notes.

Probably the most effective way to prevent or minimize risks associated with dispensing based on telehealth scripts is to verify prescribers’ licensure and ensure that they are authorized to prescribe across state lines (if applicable). I recently came across a very useful resource prepared by the Federation of State Medical Boards outlining each state’s telehealth laws and waivers due to the pandemic. Click here for the survey.

Normally, a telehealth provider must be licensed in a state of the patient’s residence. Due to the pandemic, however, many states enacted waivers allowing out-of-state prescribing. Even the DEA – during the public health emergency – has enacted a new regulation providing that “DEA-registered practitioners may prescribe controlled substances to patients in states in which they are not registered with DEA via telemedicine” (provided that they are registered in another state).

Because enforcement actions on telehealth providers have been vigorous, I encourage you to consult the survey to understand whether your prescriptions comply with telehealth requirements.

A side note: in 2020, we’ve seen the largest crackdown on telehealth providers. The Department of Justice announced $4.5 billion in allegedly false and fraudulent claims submitted by more than 86 criminal defendants in 19 judicial districts all relating to telehealth schemes. These numbers alone should motivate you to research where your prescriptions are coming from and if they are coming by means of telehealth inquire whether such prescriptions comply with state laws applicable to telehealth prescribing.