Preparing for and Responding to a PBM Audit

There is an old saying: “Possession is 9/10ths of the law.”  At the end of the day, the PBM possesses the pharmacy’s money.  If the PBM withholds payment at the outset or recoups payments at a later time, then this poses a headache for the pharmacy.  Recoupment of payments results from post-payment audits.  That is, the PBM asks the pharmacy for documentation that justifies claims (i) previously submitted by the pharmacy and (ii) paid by the PBM.  If the PBM determines that the documentation does not support the claims, then the PBM will seek recoupment.  It is critical that the pharmacy know how to properly respond to an audit to reduce the risk of recoupment.  This webinar will discuss the steps that the pharmacy should take when it is notified of a PBM audit.  The steps that will be discussed will include (i) understanding what it is that the PBM is looking for; (ii) whether it is appropriate to request that the scope of the audit be narrowed and, if so, how to make such a request; (iii) whether it is appropriate to request an extension of time to submit documents and, if so, how to make such a request; (iv) if patient documentation is deficient, then how the pharmacy may be able to rehabilitate the documentation before submitting it; (v) how to organize documentation before it is submitted; (vi) how to succinctly draft an explanatory cover letter to go with the documentation when it is submitted; (vii) how to supplement documentation after initial submission; and (viii) verbal and written discussions that the pharmacy can have with the PBM following submission of documents with the goal of influencing the results of the audit. 

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