NABP DDA: New Process & “Ineligibility Matrix”
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A PBM audit often invokes a great sense of dread by all the pharmacy’s employees but especially for the pharmacy owner. In 2020, the average PBM audit cost pharmacies close to $24k. This represents a 35% increase of the previous five years. To add to this stressful situation, the COVID-19 Public Health Emergency (PHE) has made the audit process more burdensome on pharmacies for reasons that we will discuss shortly.

The Harmful Effects of PBM Audits

The most obvious negative outcome is the potential massive financial losses, but a PBM audit may also result in network termination, license penalties and/or discipline, fines, loss of reputation and even imprisonment. Many people think that just by accepting the monetary loss then the pharmacy can avoid the other possible repercussions, but this is not true. PBMs have the power, unfortunately, to impose any and all consequences they wish if they deem that the pharmacy has breached their contract. In some cases, a pharmacy may resolve all issues of the audit without even so much as a chargeback, yet still received a complaint from the pharmacy’s state board of pharmacy that was initiated by the PBM. In these situations, the board of pharmacy is required to investigate all complaints received and may or may not move forward with fines or discipline.

Top Reasons for PBM Pharmacy Audits

1. Incorrect days’ supply 2. Missing signature log 3. Waived copayments 4. Missing inventory invoices 5. NDC mismatch 6. Can’t verify refill requests 7. Failure to reverse claims after 14 days in waiting bin

Prevent Audits from Happening

Document, document, document! Maintaining proper documentation is the simplest way to avoid audits from happening in the first place. Pharmacy owners can also train their staff in preventing fraud, waste and abuse by implementing programs and suggesting online courses to identify a bad situation before it happens. It’s also a good idea to research the laws and regulations in your state to know your rights as a healthcare provider.


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