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Many pharmacy owners believe that only significant financial discrepancies uncovered during a Pharmacy Benefit Manager (PBM) audit will lead to serious consequences. However, this is not the case. Pharmacies can face network termination even when audit findings involve smaller sums of money. It is important for pharmacy owners to understand that even small monetary discrepancies can lead to network terminations. PBMs have broad discretion and may terminate network agreements regardless of the dollar amount identified in an audit. As a result, even nominal audit findings can jeopardize a pharmacy’s network status.
PBM Audit Practices
PBMs routinely audit independent pharmacies across the country. During these audits, PBMs typically review prescription records, billing practices and documentation procedures. While the alleged goal is to identify and correct errors, the process is often rigorous and highly detailed. Inconsistencies, including incomplete documentation, clerical errors or deviations from policy, can result in negative audit findings. Because PBMs give themselves wide latitude in interpreting audit results, it is essential for pharmacies to maintain meticulous records and adhere strictly to all requirements to minimize the risk of adverse actions, including termination.
Best Practices for Pharmacies
Pharmacies should stay vigilant in preparing for a PBM audit. As mentioned above, the audit process can be highly detailed and time-consuming. Audit discrepancies can result in serious consequences such as payment suspensions or terminations. To remain prepared for an audit, pharmacies should consider the following best practices:
- Emphasize Compliance: Regularly review and update your procedures to ensure full compliance with PBM requirements.
- Maintain Thorough Documentation: Ensure all records are complete, accurate, and readily accessible.
- Respond Promptly: Address all PBM communications and audit requests in a timely and thorough manner.
- Seek Professional Guidance: Consider consulting with competent experts in pharmacy compliance, including competent legal counsel and those familiar with the PBM relationship, to identify and address potential risks.
Conclusion
Even minor audit discrepancies can have significant consequences for a pharmacy’s continued participation in PBM networks. By prioritizing compliance, thorough documentation and proactive communication, pharmacies can reduce their risk of termination and safeguard their ability to serve patients. Taking these steps not only protects the business but also ensures that patients continue to have access to the care and services they rely on from their trusted community pharmacy.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
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