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Defending a Pharmacy Benefit Manager (PBM) audit

By June 6, 2024June 14th, 2024Healthcare Audit

Defending a Pharmacy Benefit Manager (PBM) audit involves several key steps to ensure compliance, accuracy, and proper documentation. Here are the steps to 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.

Defending a Pharmacy Benefit Manager (PBM) audit

Ansari Law Firm

Author Ansari Law Firm

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