Q&A: Common Reasons Independent Pharmacies Face PBM Audits

At the National Community Pharmacists Association (NCPA) 2024 Annual Convention and Expo, held October 26 to 29 in Columbus, Ohio, Trent Thiede, PharmD, MBA, president of PAAS National, gave a presentation titled “Equipping Your Team for Typical and Atypical PBM Audit Scenarios,” in which he reviewed the latest trends in Pharmacy Benefit Manager (PBM) audits and shared tips to proactively mitigate and respond to them.

Q&A: Common Reasons Independent Pharmacies Face PBM Audits / ultramansk - stock.adobe.com

Audits are routinely conduct by PBMs with the stated goal of preventing fraud, waste, and abuse in medication dispensing. However, these audits often lack clear metrics and can include certain requirements without an explicit reason why. In 2023, PBM audits rose by as much as 29% and many pharmacists who have failed them cite it as the primary reason why they can’t stay in business.

Drug Topics sat down with Thiede at the meeting to discuss his presentation, some of the common reasons that independent pharmacies face audits from PBMs, and best practices that pharmacy teams can implement to proactively prevent audit issues before they arise.

Click here to view the full interview with Trent Thiede.

Drug Topics: What are some of the most common reasons independent pharmacies face audits from PBMs, and how have these audit tactics evolved in recent years?

Trent Thiede, PharmD, MBA: There's a couple of facets to audits, and we always think about audits in terms of outliers and claim discrepancies. Pharmacies are billing claims throughout the day, and unknowingly, they often send up red flags for different discrepancies, whether they're re-billing a claim multiple times or in comparison to their peers.

Audits are not random. They're very targeted. They know what they're looking for. They look at high dollar claims, insulin products, and so PBMs are targeted in their audits. We noticed a 17% increase year over year in the number of audits to independent pharmacies. They're all very targeted. From a common billing standpoint, they look at making sure that there are all the elements of a prescription meets state and federal requirements. They're looking to make sure there's proof of dispensing and proof of copay collection—those are kind of two newer things that have really ramped up in the last 2 years.

Click here to view all of our NCPA conference coverage.

Coverage of the National Community Pharmacists Association 2024 Annual Convention and Expo was supported by Red Sail, with independent editorial content creation on-site by the Drug Topics team.