PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
LTC Pharmacy Audits: Cycle Fills and Emergency Kits
How PBMs test days-supply math against LTC cycle fill schedules, the facility records an audit response requires, and the DEA rule…
Fraud, Waste and Abuse Referrals After a PBM Audit
How a PBM audit finding becomes a fraud, waste, and abuse referral, where the referral can go, and the False Claims Act and OIG ex…
Express Scripts Pharmacy Audit: How to Respond
How Express Scripts audits pharmacy claims, the discrepancy findings it leads with, and the response and appeal deadlines that fol…
Elixir Pharmacy Audit Defense
Elixir gives pharmacies 30 days to respond to and appeal an audit, but its Network Compliance Committee can suspend a pharmacy on…
Effective Rate Guarantees and Pharmacy Reimbursement Disputes
How PBM effective rate guarantees average reimbursement across claims, why individual fills can still pay below cost, and how phar…
DME Billed Through a Pharmacy: Audit Exposure
Supplier standards, proof of delivery, and why DME claims billed through a pharmacy draw separate CMS and PBM audit review.
DIR Fees After the 2024 Reform: What Changed
How the CMS point-of-sale rule changed Medicare Part D DIR fees on January 1, 2024, and what PBM fee disputes remain contestable.
Days Supply Miscalculation: A Top PBM Audit Discrepancy
How days supply and quantity mismatches on insulin, inhaler, and topical claims trigger PBM recoupment, and how pharmacies correct…
Coordination of Benefits Errors in PBM Audits
How the NCPDP Other Coverage Code drives PBM coordination of benefits findings, and why COB errors trigger a full claim reversal a…