Experienced Pharmacist | Seasoned
Business Leaders | Practicing Lawyers

PBM Audits

PBM audits are the single biggest threat to your business. They cost pharmacies thousands of dollars a year and can force honest business owners into bankruptcy. You need the PBM audit experts at Boesen & Snow law firm on your side so you’re fully prepared when auditors come knocking–and they will.

Get Expert Support

When PBM is on your doorstep, Boesen & Snow has your back.

  • Reduce or eliminate PBM audit fines
  • Ensure compliance with documentation best practices
  • Implement standard operating procedures
  • Deal productively with PBM auditors

The PBM Audit Defense Experts

Boesen & Snow is the pharmacy law firm with the expertise you need to protect and fight against hefty PBM claw backs and fines. As one of a very few legal teams who truly specialize in pharmacy law, you not only get the experience of attorneys and registered pharmacists but the insight of a former PBM lead auditor and a wealth of business knowledge.  

Received a PBM audit request? Do not try to respond on your own.  Your initial responses can be used against you.  You may not be able to correct incomplete or inaccurate responses in an appeal.  Call us immediately.

PBM Audits Shouldn’t Be a Cost of Doing Business

Every independent pharmacy owner loses sleep over PBM audits. Unfortunately, recent changes to pharmaceutical industry legislation will only mean an increase in audit requests. And when profit margins are already low, one bad audit outcome can have a devastating effect on your bottom line. Preparation is key and choosing the right representation matters.

PBM Audit Preparation

The best way to handle incoming PBM audits is to be proactively prepared for them. From training you on how to implement standard operating procedures to ensuring proper, thorough documentation, Boesen & Snow provides the full breadth of services to help you build a sustainable business. Reach out now.

PBM Audit Response

Most pharmacists don’t seek help until it’s almost too late. And even then, they turn to cookie-cutter consultants who charge a premium for subpar results. Your initial response to a PBM request needs to be both strategic and immediate. Boesen & Snow provides comprehensive PBM audit responses. Reach out now.

PBM Audit Defense

The higher the prescription charges, the greater the chance for an audit. With a former auditor on our team who has spent years fining pharmacists for non-compliance, Boesen & Snow knows the ins & outs of the PBM business. We work hard (and smart) to fight for your rights and your livelihood. Reach out now.

PBM Network Benefits

As the official middleman between health plans  and pharmacists, PBMs have the upper hand when it comes to prescription reimbursements. It’s an unfair fact: Unless a Mom & Pop pharmacy belongs to the same in-network benefits program that big pharmacies enjoy, they often receive lower prescription reimbursement. Boesen & Snow will fight for your right to equality. Reach out now.

Our Attorney’s

A Winning Approach to Solving your Challenges

At Boesen & Snow, we’re not only on your side but we’ve been in your shoes. Founding partner Mark Boesen has been a licensed pharmacist for the past 25 years. He understands– and has experienced, the challenges you face both from a regulatory and business perspective. 

Founding partner Allyson Snow has spent over a decade practicing in the medical and family services industries, most notably advocating for the disabled and the elderly. She now champions the rights of independent pharmacies and brings a wealth of business experience to her clients.

Mark Ziegler joined the firm as Director of Pharmacy Services after serving as one of Boesen & Snow’s most formidable adversaries. A former PBM auditor for one of the largest pharmacy benefit management companies in the country, he brings our clients unmatched insight into the auditing process. 

PBM audits are an unfortunate reality. Today’s pharmacies need more than a standard business law firm.

Click Here if You’re being Audited

 

FAQ

How do I respond to a PBM Investigative/SIU Audit?

The most important factor in responding to a PBM audit is providing the most complete and accurate documentation requested by the initial audit request deadline. This will help minimize the number of preliminary discrepancies that must be appealed during the audit while decreasing the potential financial burden to your pharmacy. Additionally, providing incomplete documentation puts your pharmacy at risk for an increased number of preliminary discrepancies which are much more difficult to overcome during the audit appeal phase. Finally, an incomplete initial audit response may lead to payment suspension and/or potential termination of your Pharmacy’s PBM Contract.
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Will hiring an attorney negatively affect my PBM Audit?

Hiring an experienced attorney to assist with a PBM audit does not have a negative effect on the results of your PBM Audit. If anything, hiring an attorney shows you take your PBM Contract seriously and are looking for guidance in providing the most complete and comprehensive response possible to the PBM Audit request. Additionally, PBM Contract language can be confusing and overwhelming, hiring an experienced attorney will bring peace of mind while navigating and responding to the PBM Audit request.
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What documents am I required to provide during a PBM Audit?

PBM Provider Manuals generally contain language listing the specific types of documentation the PBM may request during an audit with the stipulation of “including but not limited to.” Effectively responding involves providing a timely and complete response without providing documentation the PBM is not privy to or by answering “trap” questions that are not directly related to provisions of the Provider Agreement.
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How do I appeal a PBM Contract Termination?

PBM Contract Termination Notifications are frightening and overwhelming. Certain PBMs offer you the chance to appeal and present documentation to remedy the issues leading to potential termination, while others may simply terminate your contract without an additional opportunity to appeal. PBM Provider Agreements offer a Dispute Resolution process which involves Dispute Resolution discussions. If the Dispute Resolution process fails, the next step requires Arbitration, which can be extremely expensive and time consuming.
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What is a PBM Payment Suspension?

PBM Payment Suspensions are the withholding of funds in response to potential contract violations or PBM Audit findings. The PBM suspends payments to begin recouping funds in anticipation of audit findings which is within the parameters of the PBM’s Provider Agreement. Additionally, you are contractually required to continue to adjudicate claims and dispense medications to patients while on Payment Suspension. Contesting a payment suspension requires an assessment of the basis for the suspension, opening lines of communication with the PBM, and providing a corresponding appeal, including documentation, to refute the basis for the suspension.
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