Pharmacy benefit manager (PBM) audits are becoming increasingly dangerous for pharmacies. While the role of the PBM was initially to reduce costs for all parties involved, abusive PBM practices have led to the opposite in many cases. The problem has become so significant that several states have adopted legislation aimed specifically at targeting abusive PBM practices, and the National Community Pharmacists Association (NCPA) and other organizations have launched wide-reaching lobbying and advocacy campaigns in recent years.
One major issue that negatively impacts both pharmacies and patients is the lack of transparency. As the NCPA explains, “[a] lack of transparency in PBM practices has led several states to implement licensure/registration, fair pharmacy audit, or generic drug pricing legislation to try to level the playing field for pharmacies and patients.” In a white paper discussing pharmacy benefit manager (PBM) abuses, the NCPA also notes that “[w]hile PBMs claim audits are used to detect fraud, waste, and abuse, examples show they recoup payments based on small clerical errors rather than focusing on whether the correct patient received the correct dosage of the correct medication on the correct date.”
These considerations impact how pharmacies need to approach Pharmacy Benefit Manager (PBM) audits. Rather than viewing these pharmacy audits as neutral inquiries focused on ensuring accurate billing and payment, pharmacies must view them as adversarial proceedings. While a certain amount of cooperation may be warranted, pharmacies targeted in PBM audits need to take a defensive posture—and they need to be prepared to dispute false and abusive retraction demands during (and potentially after) the audit process.