PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Telehealth-Originated Prescriptions in PBM Audits
PBMs are increasingly recouping on prescriptions written through telehealth, citing invalid prescriber relationships. Here is how…
Signature Log Deficiencies: The Most Common Audit Finding
A missing or illegible signature is one of the most common PBM audit findings pharmacies face, and one of the most recoverable wit…
Self-Auditing Your Pharmacy Before the PBM Does
How pharmacies can sample their own claims, fix the systemic cause behind errors, and document the fix before a PBM audit finds it…
Responding to a PBM Audit While Short-Staffed
How to triage a PBM audit response when your pharmacy is short-staffed, what a technician can handle, and what needs the pharmacis…
Preserving Your Appeal Rights in a PBM Audit
Waiver traps hide in the correspondence that comes before the formal appeal. What preserves a pharmacy's PBM audit appeal rights,…
Pharmacy Audit Documentation Retention Requirements
Medicare Part D, PBM contracts, and state pharmacy boards each set a different retention clock, and purging early can cost a pharm…
Pharmacy Technician Errors That Become Audit Findings
DAW code slips, days' supply miscalculations, and refill-too-soon overrides at the technician level routinely become PBM recoupmen…
Pharmacy Audit Defense: What Actually Reverses a Finding
PBM audit findings get reversed on three grounds: documentation the auditor rejected, ambiguous contract terms, and procedural def…
PBM Audits and Your Wholesaler Relationship
PBM invoice reconciliation audits can turn a pharmacy's wholesaler purchase records into a recoupment finding, even when shelf inv…