PBM Audit Attorney

A PBM (Pharmacy Benefit Manager) audit is a review process where an organization’s pharmacy benefit manager’s activities and practices are examined to ensure compliance with contractual obligations, regulations, and industry standards. PBMs act as intermediaries between insurers, pharmacies, and drug manufacturers to manage prescription drug benefits on behalf of health plans.

Here are the key aspects typically involved in a PBM audit:

Claims Review: Evaluating the accuracy and legitimacy of prescription claims processed by the PBM.

Contract Compliance: Ensuring the PBM adheres to the terms and conditions specified in the contract with the employer or health plan.

Rebate Management: Verifying that the PBM appropriately manages and passes through manufacturer rebates to the client.

Formulary Management: Reviewing the PBM’s formulary decisions to ensure they align with clinical guidelines and contractual agreements.

Pricing and Discounts: Checking the pricing structures, discounts, and fees applied to the prescriptions to ensure they are transparent and fair.

Network Adequacy: Assessing the network of pharmacies to ensure it meets the accessibility and coverage requirements of the contract.

Compliance with Regulations: Ensuring the PBM complies with federal and state regulations governing pharmacy benefits.

Data Integrity: Verifying the accuracy and integrity of data related to prescription drug claims and patient information.

Financial Accuracy: Confirming that financial transactions, including payments and reimbursements, are accurate and properly documented.

PBM audits are conducted to protect the interests of the clients, ensure transparency, and maintain the integrity of the pharmacy benefit management process.