What to Expect at Each Stage of a PBM Audit

A pharmacy benefit manager (PBM) audit may not announce itself as a serious problem. It arrives as a documentation request with a deadline, and it looks like paperwork. Left alone, that paperwork can turn into a significant recoupment demand, a payment suspension, or termination from the network.

This guide walks through six stages of a PBM audit and what shapes the outcome at each one. Written by Mark Boesen, Pharm.D., J.D., founding partner at Boesen & Snow Law, and Mark K. Ziegler, Pharm.D., M.B.A., Director of Payor Compliance & Credentialing (non-attorney).

What you will learn:

• Where the requirements a PBM may apply are typically found
• Documentation issues that pharmacies commonly encounter
• Why the initial submission carries more weight than pharmacies often expect
• What tends to trip pharmacies up at each stage of the audit
• How legal counsel can help at any point in the process

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Attorney Advertising. This white paper is provided for general informational and educational purposes only and does not constitute legal advice. The information contained in it is not intended to create, and the receipt or use of it does not constitute or create, an attorney-client relationship between the reader and Boesen & Snow Law. Readers should not act, or refrain from acting, on the basis of any information included in this document without first seeking the advice of qualified legal counsel regarding their own particular facts and circumstances. Prior results described or referenced herein do not guarantee a similar outcome.

Boesen & Snow Law is based in Scottsdale, Arizona. We work with independent, multi-location, and limited-distribution pharmacies nationwide on PBM audit, network, and compliance matters. Our ability to formally represent a pharmacy in a particular matter, including in litigation, arbitration, or before a state board, depends on that jurisdiction’s licensure and admission requirements, which may include pro hac vice admission or association with local counsel. Contact us to confirm we can assist with your pharmacy’s specific state and matter.

For more information, contact [email protected].

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