Defending a Pharmacy Benefit Manager (PBM) audit involves several key steps to ensure compliance, accuracy, and proper documentation. Below is a structured guide to help you effectively defend a PBM audit.
1. Preparation and Organization
Document Management
- Ensure all pharmacy records, including prescriptions, invoices, and patient information, are well-organized and easily accessible.
Audit Guidelines
- Familiarize yourself with the audit guidelines and requirements provided by the PBM.
Training
- Train your staff on audit procedures and the importance of accurate record-keeping.
2. Understand the Scope
Audit Notification
- Review the audit notification letter carefully to understand the scope, time frame, and specific areas of focus.
Clarify Doubts
- If there are any ambiguities or unclear instructions in the audit notification, contact the PBM for clarification.
3. Internal Review
Pre-Audit Self-Check
- Conduct an internal review of your records and processes to identify and rectify any discrepancies before the audit.
Check Compliance
- Ensure that all procedures comply with PBM contracts, state, and federal regulations.
4. Gather Required Documentation
Prescription Records
- Ensure all prescriptions are complete with necessary details such as prescriber information, dosage, and patient information.
Billing Records
- Verify that all billing records match the prescriptions and any overrides or adjustments are properly documented.
Patient Records
- Keep accurate and updated patient records to demonstrate adherence to prescribed therapies and medications.
5. Audit Day Protocol
Designate a Point Person
- Assign a knowledgeable staff member to coordinate with the auditors and provide them with requested information.
Provide Workspace
- Ensure that the auditors have a quiet and comfortable workspace to conduct their review.
Be Cooperative
- Be courteous and cooperative with the auditors, and provide them with the information they request promptly.
6. Responding to Findings
Review Audit Report
- Carefully review the preliminary audit findings and compare them with your records.
Prepare Responses
- Prepare detailed and factual responses to any discrepancies or issues noted in the audit report.
Provide Additional Documentation
- If necessary, provide additional documentation or clarification to address the auditor’s findings.
7. Follow-Up
Corrective Actions
- Implement any corrective actions required to address deficiencies identified during the audit.
Policy Updates
- Update your policies and procedures to prevent future issues and ensure compliance with PBM requirements.
Staff Training
- Conduct additional training sessions for your staff based on the audit findings to improve future performance.
8. Legal Assistance
Consult Legal Counsel
- If the audit results in significant disputes or potential legal implications, consult with a legal professional experienced in healthcare law and PBM audits.
Documentation
- Maintain all correspondence, documentation, and evidence related to the audit for future reference and potential appeals.
By following these steps, you can effectively defend a PBM audit and demonstrate compliance with PBM guidelines and regulations.
Frequently Asked Questions
What is a Pharmacy Benefit Manager (PBM) audit?
A PBM audit is a formal review conducted by a Pharmacy Benefit Manager to ensure that a pharmacy’s billing practices, documentation, and patient care procedures comply with contractual and regulatory requirements.
How should I prepare my pharmacy for a PBM audit?
Start by organizing all necessary records, prescriptions, billing, and patient data. Train your staff on audit procedures, familiarize yourself with the PBM’s audit guidelines, and perform an internal review to fix discrepancies beforehand.
What happens on the day of a PBM audit?
On audit day, designate a knowledgeable staff member to assist auditors, provide them with a quiet workspace, and ensure full cooperation by delivering requested information promptly and respectfully.
What should I do if discrepancies are found during the audit?
Carefully review the audit findings, compare them with your own records, and provide factual responses. Include additional documentation if needed to clarify or contest any issues noted.
Is legal help necessary during a PBM audit?
Legal counsel is not always required but can be essential if the audit reveals major compliance issues or financial liabilities. A healthcare attorney can assist with appeals or disputes arising from the audit findings.