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PHARMA360 GUIDES · FOR INDEPENDENT PHARMACY OWNERS

How to prepare for a PBM on-site audit

To prepare for a PBM on-site audit, read the audit notice for the visit date, the auditor, the claims or period under review and any records requested in advance; then pull and organize those records, check that licenses and registrations are current and easy to produce, name one staff member to host the auditor, and plan how the pharmacy will keep serving patients during the visit. An on-site audit is a visit in which an auditor reviews prescriptions and claims in person at the pharmacy, and may also look at inventory, records and operations.

By Raza Hasan, RPh, Chief Pharmacist & Consultant, Pharma360 Solutions · 32+ years in the pharmacy business

General information for pharmacy owners, not legal advice. Deadlines and requirements are set by your PBM contract and audit notice; always check the notice.

Before the visit

  1. Confirm the visit. Check the date, time and auditor named in the notice. If anything looks unusual, confirm the audit with the PBM using the contact details in your contract or provider materials, not only those on the letter.
  2. Read the notice for scope: the claims, the review period and any records the auditor wants ready on arrival. If the timing does not work, ask in writing, as soon as possible, whether the visit can be moved; your contract governs what is allowed.
  3. Pull the records for the listed claims and organize them claim by claim, using the audit documentation checklist.
  4. Reconcile purchases against dispensing for the drugs most likely to be reviewed, so you understand any gaps before the auditor raises them.
  5. Gather current pharmacy licenses, permits and registrations, pharmacist license information and written policies and procedures.
  6. Prepare a quiet workspace away from the counter, with access to the records the auditor will need.
  7. Choose a host and a backup, and brief the rest of the staff on who answers the auditor’s questions.

During the visit

  • Ask the auditor to explain the scope and the agenda at the start.
  • Keep the host available, and answer questions factually. If you do not know an answer, say you will check and follow up rather than guessing.
  • Keep a log of every record the auditor reviews, copies or takes away.
  • Note any requests for documents you could not produce on the day, and the date by which they are due.
  • Read anything you are asked to sign and ask questions if it is unclear; you can ask for time to review it.
  • Before the auditor leaves, ask what happens next and how findings will be communicated.

After the visit

Write up your notes the same day while details are fresh. Send any follow-up documents you promised, complete and organized, by the date agreed. Then watch for preliminary findings. When they arrive, check them against your records and your visit log, and follow the steps in our guide to the PBM audit appeal process. If the PBM asks for records to be mailed instead of visiting, see how to respond to a PBM desk audit.

Frequently asked questions

How much notice will I get before a PBM on-site audit?

Notice requirements are set by your PBM contract and any rules that apply, and they vary. The audit notice gives the scheduled date, so read it as soon as it arrives.

Can I reschedule a PBM on-site audit?

Ask the PBM or audit company in writing as soon as you know the date does not work. Whether the visit can be moved depends on your contract and the auditor.

What do auditors usually look at during an on-site audit?

Typically prescriptions and claims for a selected period, signature or delivery records and purchase invoices, and often inventory, licenses, policies and general operations.

Can someone help us during the visit?

Yes. Many pharmacies have a consultant available by phone to help with questions and follow-up. If legal representation is needed, Pharma360 provides it through licensed attorneys.

Official sources

Talk to Pharma360

Have an on-site audit scheduled? Pharma360 helps independent pharmacies prepare for the visit and respond to the findings. See our pbm audit defense 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.

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