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PBM Audit Best Practices : Tips for PBM Audits from an Industry Insider

The primary goal of the PBM Audit is to uncover discrepant claims and recoup money paid to your pharmacy. What most pharmacies do not realize is that even minor audit findings can result in network terminations. All adjudicated claims are subject to audit regardless of the fact the claim paid. Boesen & Snow offers proactive advice and solutions to help you mitigate the risks PBM audits present. PBM provider manuals include hundreds of pages of hidden traps waiting to trip you up and justify aggressive PBM action.  If your Pharmacy has been notified of an audit, contact our experienced PBM audit defense team. Please click the box below, your responses will be immediately sent to our PBM Audit Specialist.

The key points in mitigating PBM audit findings include:

  • Proactive PBM Provider Manual Compliance
  • Complete, Accurate, and Effective Initial Audit Responses
    • Organized
    • Complete
    • On Time

What the Other Audit Services are Not Telling You:

PBM Auditors wield the power of one-sided provider agreements, unlimited resources, and unforgiving auditors.  Every step of the PBM audit is an opportunity to identify a missing process, data point, or document that can justify harsh contractual punishments. Everything you say and every document you provide can be used against you in unforeseen ways.

Your Boesen & Snow audit team will include a pharmacist, an attorney, and a former PBM lead auditor who know the process inside and out.  They can help your business respond to desktop and onsite audits to achieve the best results the first time.  There is no “routine” audit that a non-attorney consult or inexperienced law firm can handle. The point of the audit is to find discrepancies and take your money.  Do not trust your business with advisors who do not understand the danger lurking in every PBM audit.

PBM Audits are a reality all pharmacies face—it is not a matter of if but when. Proactive measures include Pharmacy Operations review, developing Policies and Procedures and corrective actions, staff training, continuing compliance review.  When audits come, Boesen & Snow can help with organized, accurate, and timely responses.  Prevent the need to hire Boesen & Snow to appeal negative audit findings by engaging the firm before trouble hits.

Services Audit Preparation

  • Gathering and Maintaining Records and Data Compliant Drug Inventory Acquisition and Management
  • Documenting Professional Actions, Patient Consent, Copayment Collection, Delivery, and Signature
  • Compliant Claim Submission Practices

Audit Response

  • Understanding the Type of Audit and the Necessary Responses
  • Identifying Required Documentation and Troubleshooting
  • Evaluating and Responding to Audit Discrepancies
  • Fighting Back through Appeals, Arbitrations, and Litigation

Common Audit Findings

  • Invoice Shortages
    • Poorly Documented Drug Acquisitions
    • Purchases Before and After the Audit Period
    • Pharmacy to Pharmacy Transfers
    • Help prepare proof of business to business financial transaction if requested
    • Prepare explanation for limited purchases as they apply to pharmacy operations
  • Member and Prescriber Denials
    • Member denied requesting prescription
    • Member denied receiving prescription
    • Member denied payment of copay
    • Prescriber denies writing prescription or failed to create valid prescriber-patient relationship
  • Copay Collection
    • Failure to collect copayment
    • Inappropriate application of coupons and secondary benefits
    • Failure to document collection and deposit of copayment
    • Inadequate financial assistance program or demonstration of financial hardship

Post Audit Functions

  • Post-audit Appeals, Arbitration, and Litigation
  • Preparation of Corrective Action Plans
  • Dialogue and Settlement with PBM Contacts

Other PBM Services Offered

  • Network Enrollment and Appeals of Network Enrollment Denials
  • Change of Ownership
  • New Pharmacy Contracting
  • Mail/Retail PBM Contracting
  • Obtain Provider Identification Numbers (NPI, NCPDP)
  • Prepare Accreditation Applications (URAC, etc.)

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