PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
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…
Compound Claim Audits: What PBMs Look For
How PBMs review compound claims ingredient by ingredient, the pricing hurdles compounds create, and the records that support a cla…
Centene and Envolve Pharmacy Audits
State Medicaid contracts route audit and network termination authority through Centene's Envolve Pharmacy Solutions to network pha…
CarelonRx Pharmacy Audit Defense
CarelonRx audits carry the same recoupment, SIU referral and network termination exposure as any major PBM, with appeal rights set…
Capital Rx Audit: What Independent Pharmacies Should Expect
Capital Rx has rebranded to Judi Rx, but its transparent-model claim audits still carry the same recoupment risk and appeal deadli…
Any Willing Provider Laws and PBM Network Exclusion
Any willing provider laws can force a PBM to reinstate an excluded pharmacy, but ERISA preemption limits how far the statute reach…
340B Contract Pharmacy Audits: Duplicate Discount Risk
Duplicate discount findings at 340B contract pharmacies land on the covered entity. How HRSA, manufacturer, and PBM audits differ,…
Signature Log Findings in Pharmacy Audits and How to Rebut Them
A signature log finding can trigger a full recoupment demand. Learn what alternative proof of dispensing evidence pharmacies use t…