Tackling PBM Audits

“Pharmacy Benefit Manager (PBM) audits are fun!” said no one ever.

Unfortunately, PBM audits are a fact of life for independent community pharmacists. They cost you money and require a lot of work. But by working collaboratively with your PBM, you could avoid audits completely or make the process a lot easier to get through.

Why do audits happen? Because of rising healthcare costs and updated data analytics that can find outliers with ease. There are also bad actors out there taking advantage of the system. They’ve led to a 50 percent increase in audits in over five years.

The most common form is desktop audits. There are also onsite audits, however, they decreased due to COVID-19. Virtual audits took their place, but this type of audit is very large and time consuming, and it requires a phone interview with the auditor.

If you’d like to prevent audits, implement these four strategy elements into your practice:

  • Prescriptions: Be sure that there’s a prescription, and check to be sure that it meets the requirements of the state and federal government.
  • Data entry and filling: Make sure that this information was filled out correctly and that it’s accurate.
  • Dispensing: You need to be able to show proof of dispensing and the collection of copay.
  • Invoice: Confirm that enough inventory has been purchased from appropriate sources.

Common audit discrepancies include prescriptions that were missing elements; transferred prescriptions missing transfer elements; overfilling prescriptions; refills filled too soon; and dispensing outside of a return to stock.

If you need a better way to make an audit easier, try including some of the following strategies as a key part of the dispensing process:

Dropoff: Train your staff on alterations that can be made to prescriptions, such as the quantity or date. Have them check instructions. Are they vague? If clarification is needed, your staff should document with a notation:

  • The name and title of whom they spoke with
  • The date and time of the call
  • Details of the conversation
  • The initials of the staff member

Data entry: Is the correct National Counsel for Prescription Drug Programs billing unit included on the claim? Make sure the day supply has been calculated according to quantity and directions. Do not rely on what comes through eScript. It’s often inaccurate.

Filling: Staff should match the 11-digit code from the National Drug Code (found on the bottle next to the billing label). You can simplify this process by using a barcode scanning system.

Cashier: Your staff needs to make sure they’re getting the patient’s signature at the time of dispensing. Are they mailing the prescription? If so, have them find the tracking information and link it to the prescription number. PBMs will want to know what’s in a delivered package.

Collect the copays and the proof of the copays. It’s also imperative to stay on top of return to stock. These are easy pickings for PBMs.

If an audit is needed, don’t take it on by yourself and leave out your staff. This is a bad idea. Your staff needs to know what drugs can trip an audit. Educate your staff well, and audits can be a lot easier to get through.


A Member-Owned Company Serving Independent Pharmacies

PBA Health is dedicated to helping independent pharmacies reach their full potential on the buy-side of their business. Founded and owned by pharmacists, PBA Health serves independent pharmacies with group purchasing services, wholesaler contract negotiations, proprietary purchasing tools, and more.

An HDA member, PBA Health operates its own NABP-accredited secondary wholesaler with more than 6,000 SKUs, including brands, generics, narcotics CII-CV, cold-storage products, and over-the-counter (OTC) products — offering the lowest prices in the secondary market.

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