Buchanan’s PBM & Pharmacy Practice Group Reduce PBM Audit Findings By 100%

Audits conducted by Pharmacy Benefit Managers (PBMs) pose a significant risk to the financial stability and daily operations of independent pharmacies. What may begin as a routine audit can quickly escalate into substantial repayment demands, network exclusion threats or even allegations of fraud that could be reported to federal and state regulators. Many pharmacies feel overwhelmed by the complexity and scope of these audits, but a strategic and thorough response can make a decisive difference.

Buchanan recently represented an independent pharmacy facing nearly $400,000 in alleged discrepancies following a PBM audit. Through careful review of the audit report and the pharmacy’s detailed records, Buchanan achieved a complete elimination of the alleged discrepancies and corresponding financial recoupment.

Buchanan’s Approach

Buchanan’s legal team conducted a meticulous, claim-by-claim analysis of the PBM’s findings. Working closely with the pharmacy, Buchanan’s team examined all relevant documentation, including prescription records, purchase invoices, dispensing logs, signature forms, delivery confirmations and supporting calculations. Each alleged discrepancy was carefully evaluated to determine whether the PBM’s conclusions were justified and accurate.

When the PBM’s findings were not supported or incorrect, the Buchanan team prepared a comprehensive appeal. Rather than relying on broad arguments, each alleged discrepancy was addressed individually. This provided clear documentation with corresponding legal support for each alleged discrepancy. This level of detail and organization often proves critical in achieving a favorable outcome.

The Result

Working in collaboration with the pharmacy and following the Buchanan Legal Team’s appeal, the PBM reversed every audit discrepancy. The pharmacy’s alleged liability was reduced by 100 percent, decreasing the audit findings to $0.00. This outcome protected the pharmacy from significant financial harm and demonstrated the importance of a rigorous, evidence-driven response.

Lessons aand Practical Takeaways for Independent Pharmacies:

1. Maintain Comprehensive Documentation
   Well-organized records such as signature logs, dispensing documentation, delivery records and clinical notes are essential for a strong audit response.
2. Respond Strategically and Specifically
   An effective audit response requires more than submitting additional documents. Each alleged discrepancy should be addressed individually, with records and legal analysis tailored to the specific issues or concerns raised by the PBM.
3. Engage Experienced Legal Counsel Early
   Involving knowledgeable attorneys at the outset of the audit process can maximize your response options and improve your prospects for a successful resolution. Delaying until recoupment demands are finalized or network participation is at risk can limit your ability to respond effectively.

Conclusion

PBM audits present complex challenges, but with the right preparation, documentation and legal strategy, pharmacies can successfully respond to even the most daunting audit findings. Buchanan’s PBM & Pharmacy Practice Group is committed to protecting independent pharmacies from unwarranted recoupment demands and ensuring their continued ability to serve their communities.