Ensure Your Team Is Prepared for PBM Audits

In an interview with Pharmacy Times at the National Association of Community Pharmacists 2024 Convention & Expo, Trent Thiede, PharmD, president of Pharmacy Audit Assistance Service (PAAS) International, discussed how pharmacy teams can remain prepared for audits from pharmacy benefit managers (PBMs).

Q: What are the common types of PBM audits that pharmacies face, and what specific documentation or records are typically requested? How do you stay informed about evolving audit requirements and best practices?

Thiede: Yeah, great question. So, the different types of audits, I'll go through just a couple of them here. The traditional is a desktop audit. We're also seeing what we call prescription validation requests or prepay audits. Those are quick turnaround, typically single claim audits, but those are the most common. They represent about 85%, probably, of all audits. We see on-site audits where an auditor is physically coming to the pharmacy to inspect records, and we also see invoice audits where the PBM is looking to validate purchases against bill claims billed over a specific period of time. So really those 4 core audits, there's other ancillary aspects to them, but those are really the 4 core audits. Now the question of what kinds of things to do, what documentation do they need? Well, traditionally, you always need to show evidence of a prescription, hard copy, front and back. Signature locks have always kind of been required, but we're seeing a lot more requests for them. Proof of delivery, if you're mailing things like that. And then also we see a ramp up of proof of copay collection. So, did the pharmacy collect cost sharing amount? PBMs are very critical of that, especially when there are high-dollar copay amounts, they question whether the pharmacy is fully collecting those in full. So, they're requiring that, as well.

How to stay on top of audits is a never-ending task. At PAAS, we see 10,000 audits a year, and we use that information and guidance to help educate our members about what things are happening in the industry. As a single independent pharmacy, it's very hard to keep up with all the changing provider manuals out there that are hundreds of pages in and of themselves, and state Medicaid requirements. There's just a lot going on, so having a good partner to help keep you educated about what things are happening is the best way to be proactive in preventing audits.

Q: Can you describe your approach to proactive audit preparation? What steps do you take to ensure that your team is organized and prepared?

Yeah, I think it's a great question. I mean, our team at PAAS is always focused on making sure they have the best tools and resources available to them. We educate them, we're constantly training, and I think from a pharmacy perspective, it really is getting them informed about what is the importance of audits, what kinds of things do we need to be aware of? And it really comes down to filing and billing claims accurately, making sure you're calculating day supply, and that comes down to, do they have the right tools and resources? Different PBMs have different requirements for certain things like eye drop calculations, so knowing what those requirements are, how do they learn that, and how do you keep your team educated, because [PBMs] do change requirements, new staff come in, staff turnover. So, it's always an evolving process that goes on continuously.