Medicare Part D pharmacy audits, explained

Who may review Part D and Medicaid pharmacy claims

• The Part D plan sponsor, or the PBM that runs its pharmacy network. This is the most common source of audits.
• Contractors working for CMS that review Medicare claims for accuracy and potential fraud, waste or abuse.
• The HHS Office of Inspector General, which oversees federal health care programs.
• For Medicaid: the state Medicaid agency, its audit contractors and, in some cases, the state’s Medicaid Fraud Control Unit.

What these reviews usually check

• That each claim is supported by a valid prescription with complete prescriber information.
• That the drug, quantity and days’ supply billed match the prescription and what was dispensed.
• Proof that the beneficiary received the medication.
• Purchase invoices that support the quantity dispensed.
• Program-specific requirements, such as prior authorization or state Medicaid rules.

Records to keep ready

Keep prescription images, signature or delivery records, refill histories and purchase invoices organized so you can find them by claim, date and NDC. Keep records for as long as your contracts and the applicable federal and state rules require; check those documents or ask a licensed attorney rather than relying on a general rule. Our audit documentation checklist covers the basics.

When a government review needs extra care

If a letter comes from a government agency or one of its contractors rather than your PBM, read it closely, note who sent it and what it asks for, and respond within the time it states. Some government reviews have legal consequences that a PBM audit does not, so many pharmacies speak with a licensed attorney before responding. Pharma360 provides legal representation through licensed attorneys under a separate scope, while the consulting team organizes the records.

Frequently asked questions