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PHARMA360 GUIDES · FOR INDEPENDENT PHARMACY OWNERS

What is a PBM audit?

A PBM audit is a review by a pharmacy benefit manager (PBM), or an audit company working for it, to check that a pharmacy’s claims were billed and documented as the PBM contract and provider manual require. The auditor selects claims, asks for records that support them, compares those records with the claims as billed, and can issue findings and ask for money back on claims it considers unsupported. The main types are desk audits, on-site audits and investigative audits, and the rules for each are set by the PBM contract, the provider manual and the audit notice.

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.

The main types of PBM audit

  • Desk audit: the PBM selects claims and the pharmacy sends supporting records remotely. No one visits. See how to respond to a PBM desk audit.
  • On-site audit: an auditor visits the pharmacy to review prescriptions, records and often inventory and operations. See how to prepare for a PBM on-site audit.
  • Invoice or inventory audit: the auditor compares the quantity of each drug the pharmacy bought with the quantity it billed. See what NDC reconciliation is.
  • Investigative audit: a broader review that a PBM may open for reasons it does not always explain. These can involve more records and longer timelines, and a licensed attorney is often involved.

What auditors usually review

  • Prescriptions: prescriber details, drug, strength, quantity, directions and any documented clarifications.
  • Claims as billed: NDC, quantity, days’ supply, refill number and dispense-as-written codes.
  • Proof the patient received the medication: signature logs or delivery records.
  • Purchase invoices that show the pharmacy bought enough of the product it billed.
  • Licenses, policies and general operations, mainly during on-site visits.

How a PBM audit usually runs

  1. The pharmacy receives an audit notice that names the claims or period, the records requested and the response date.
  2. The pharmacy sends records, or hosts the auditor on site.
  3. The PBM issues preliminary findings for claims it considers unsupported.
  4. The pharmacy can dispute findings within the time and by the method the findings letter and contract set out. See the PBM audit appeal process.
  5. The PBM issues final findings. Some PBMs offer a further level of appeal.

Why audits are routine

PBMs audit network pharmacies as a normal part of managing their networks, and an audit notice does not by itself mean anything is wrong. Pharmacies that keep records organized and spot-check recent claims find audits easier to answer. Our audit documentation checklist lists the records auditors typically ask for.

Frequently asked questions

Who conducts PBM audits?

The PBM itself or an audit company it contracts with. The audit notice names who is conducting the audit and how to contact them; confirm the audit with the PBM using the contact details in your contract.

Does an audit notice mean my pharmacy did something wrong?

No. PBMs audit network pharmacies routinely. An audit is a review of documentation against the claims as billed.

What is the difference between a PBM audit and a Medicare or Medicaid audit?

A PBM audit is run under the PBM contract. Medicare Part D claims can also be reviewed by plan sponsors and government contractors, and Medicaid claims by the state program and its contractors. See our guide to Medicare Part D pharmacy audits.

Can Pharma360 help with any type of PBM audit?

Yes. Pharma360 supports desk, on-site, invoice and investigative audits, and provides legal representation through licensed attorneys when it is needed.

Official sources

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    Received a PBM audit notice? Pharma360 helps independent pharmacies understand the request and prepare an organized response. 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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