PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Your PSAO's Role in a PBM Audit
A PSAO holds the network contract behind a PBM audit and often handles the notice and remittance, but the response deadline and pr…
Reversing and Rebilling Claims After a PBM Audit Notice
Reversing and rebilling a flagged claim after a PBM audit notice can read as concealment, not correction, under how provider manua…
State Pharmacy Audit Laws and When They Apply to a PBM Audit
Most states protect pharmacies during PBM audits through their own audit statutes, but a self-funded plan's ERISA status can chang…
Responding to a PBM Audit When Records Are Missing
A system migration, a fire, or a ransomware event does not excuse a PBM audit response. What to document, reconstruct, and disclos…
Payment Holds During a PBM Audit
When a PBM holds payment or routes claims to manual review during an audit, the provider agreement, not a government rule, control…
NDC Mismatch Findings in a PBM Audit
PBM auditors treat a billed NDC that does not match the dispensed product as unverified, not underpriced, which is why the finding…
How Far Back a PBM Can Audit Your Claims
The PBM audit lookback comes from the network agreement, then state audit law, then the contract limitations period, never a fixed…
Copay Collection Findings in PBM Audits
PBM auditors test copay collection against payment records and patient contact. A documented hardship waiver survives; an undocume…
When a PBM Audit Triggers a State Board Referral
Some PBM audit findings do not stay a reimbursement dispute. They get referred to the state board of pharmacy, putting the license…