PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Partial Fills and Audit Discrepancies
How Schedule II and III-V completion windows create billing mismatches that trigger PBM audit findings, and the documentation that…
Multi-Location Pharmacy Groups: Audit Exposure Across Stores
PBM audits opened against one store can extrapolate findings and expand network termination risk across every commonly owned pharm…
Inventory Reconciliation Shortfalls in Pharmacy Audits
PBMs flag inventory shortfalls by matching purchase invoices to billed claims. Legitimate variance and shortage-driven NDC swaps e…
Insulin and Diabetic Supply Audit Findings
PBM audits target high-utilization insulin, test strip, lancet, and CGM claims. Here is the quantity-limit and days-supply documen…
How to Write a PBM Audit Response Letter
How pharmacies structure a point-by-point rebuttal, organize exhibits, and avoid admissions that undermine a later PBM audit appea…
Controlled Substance Claims in a PBM Audit
When a PBM audit flags controlled substance claims, the same dispensing patterns can trigger DEA scrutiny. Sequencing the response…
Discount Card Claims and PBM Audit Scrutiny
Discount card claims like GoodRx route through the PBM, and a mismatched usual and customary price can trigger a full-lookback PBM…
Central Fill and Audit Documentation Gaps
How DEA rules split prescription records between originating and central fill pharmacies, and where PBM audits find the gap betwee…
Challenging Extrapolation in a PBM Audit
How PBM extrapolation turns a small audit sample into a recoupment demand covering claims that were not reviewed, and the statisti…