PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
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…
Buying a Pharmacy With an Open PBM Audit
An open PBM audit does not have to sink a pharmacy sale, but it changes how the deal should be structured, priced, and documented.
PBM Onsite Audit: How to Prepare for the Auditor Visit
How pharmacies should stage documents, designate a point of contact, and control scope before and during a PBM onsite audit visit.
PBM Invoice Audit: Proving Your Purchases
Wholesaler invoice reconciliation, shortage findings, and extrapolation: how PBM audits weigh a pharmacy's proof of purchase, and…