External Audit Defense (PBM)

PBMs (Pharmacy Benefit Managers) are 3rd parties linking health insurance companies and drug manufacturers to independent pharmacies. PBMs are supposed to reduce admin expenses for insurers, negotiate costs between health plans and pharmacies, administer plan benefits, validate patient eligibility, and more.

However, over time, PBMs have become a problem to independent pharmacies, with most using audits to make profits. PBMs are guilty of operating unchecked. Some PBM practices also lack transparency, which is precisely why some states like Kansas have special legislation on pharmacy audits and drug-pricing laws.

If you are facing an external PBM audit, Corporate Investigation Consulting can offer external audit defense. We can advise and protect you when PBMs come knocking. We can also assist with proactive measures that reduce PBM audit-related issues.

Put our highly experienced team on your side

Roger Bach
Roger Bach

Former Special Agent
(DOJ-OIG & DEA)

Timothy E. Allen
Timothy E. Allen

Former Senior Special Agent
(U.S. Secret Service & DOJ-OIG)

Chris Quick
Chris Quick

Former Special Agent
(FBI & IRS-CI)

Maura Kelley
Maura Kelley

Former Special Agent
(FBI)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent
(FBI)

Michael Koslow
Michael Koslow

Former Supervisory Special Agent
(DOD-OIG)

Marquis D. Pickett
Marquis D. Pickett

Special Agent
U.S. Secret Service (ret.)

Dennis A. Wichern
Dennis A. Wichern

Former Special Agent-in-Charge
(DEA)

Nationwide External Audit Defense (PBM)

Corporate Investigation Consulting supports independent pharmacies all over the U.S. in pharmacy benefit manager audits.

Independent pharmacies must face audits from PBMs. The audits are mandatory when signing up with a PBM. Most importantly, the audits are thorough and involve unchecked inspection of a pharmacy’s billing to drug makers and insurance companies.

While external PBM audits may not result in federal prosecution, they can lead to unfavorable outcomes such as hefty penalties.

The importance of getting expert guidance when facing a PBM audit can’t, therefore, be overlooked. You need legal experts, financial experts, and industry insiders who understand pharmacy benefit manager roles, contracts, and billing rules applicable to drug and insurance companies in regards to prescription medication.

Corporate Investigation Consulting has all the professionals and consultants needed to defend you in a pharmacy audit process. We advise on risks and handle PBM audits & investigations, challenging unfavorable audit outcomes if need be.

Protecting Your Pharmacy from PBM External Audits

Pharmacy owners can take certain measures to protect themselves from/in the event of external PBM audits. The measures include:

Keeping Proper Documentation

Poor documentation exposes pharmacy owners to problems. Failing to document everything creates avenues for unfavorable outcomes in the event of an audit. Pharmacies deal with countless documents on a daily basis. It’s impossible to remember undocumented pharmacy data. Keeping proper documentation from signature logs and invoices to early refills and supply changes makes it easy to produce such information on request.

Establish Standard Operating Procedures

SOPs (standard operating procedures) dictate how work is done. Pharmacies lacking SOPs risk having team members that do tasks differently. Moreover, without standard operating procedures in place, it’s difficult to identify mistakes early and establish strong external audit defenses when challenging audit outcomes. SOPs work more as preventative tools. If all your pharmacy staff follow standard operating procedures, external audits stop being a cause for concern.

Paying Special Focus on High-Cost Drugs

External audits tend to focus on high-cost drugs for obvious reasons making it critical to maintain proper documentation of such drugs. External audit defense is easier if there are no mistakes surrounding what auditors focus on the most. In fact, high-cost drugs should be self-audited periodically, ensuring everything adds up. A special audit process will come in handy.

Hire Experts

You can take all measures discussed above and still face external audit processes that result in unfavorable outcomes.

You need experts like Corporate Investigation Consulting to offer audit defense when your pharmacy is found culpable. You also need us when taking proactive approaches to protect your pharmacy.

Proactive External Audit Defense for PBM Audits

We have experts nationwide in all matters regarding external pharmacy audits. We can;

Intervene immediately: If your pharmacy is subjected to a PBM audit, we can intervene immediately and take charge of the process. We can challenge an auditor’s methods and assumptions. We can also enforce applicable statutory and contractual limitations. Our immediate and aggressive approach in external audit defense keeps PBM auditors accountable and protects our clients from being subjected to retractions, recoupments, and other unfavorable outcomes such as penalties.

Offer pre-audit consultation services: Pharmacy owners who get correspondence from PBMs should contact us immediately before audits commence. Through pre-audit consultation, we can anticipate potential problems and craft strategic audit defense on such issues. Letting a pharmacy benefit manager know you have experts by your side before audits can alter the audit process significantly in your favor.

Intervention during audits: We can work with auditors on your behalf, challenging improper PBM auditor demands, flawed audit methods, and other audit irregularities to save your pharmacy from penalties and other unfavorable outcomes. We intervene in audits even if your pharmacy isn’t fully compliant on issues like billing or there are other obvious issues that need action. Our experts have audit defenses available to tackle a variety of external audit matters.

Intervene post-audits: Pharmacy owners that face negative PBM audit determinations shouldn’t see such determinations as final outcomes. While pharmacies have contractual obligations in regards to billing and other areas, PBM audit determinations don’t carry dire legal consequences.

Instead, pharmacies are subjected to financial penalties and recoupments whose validity can be challenged successfully by our nationwide team of external audit defense experts. Our interventions after audit processes usually result in removal or reduction of imposed penalties.

Develop & implement pharmacy compliance programs: Besides offering external audit defense, our experts can offer support on billing compliance. We have developed comprehensive pharmacy compliance programs for many pharmacies nationwide to safeguard against unfavorable PBM audit outcomes.

Our programs also protect pharmacies from audits from other entities and fraud investigations. We can assess the unique needs of your pharmacy, establish procedures and policies as well as facilitate training for pharmacy personnel.

Corporate Investigation Consulting offers full-service audit services tailored to pharmacies. We go as far as assisting pharmacies in PBM audit litigation.

Most PBM external audit issues are resolved during an audit. However, there are instances where litigation is necessary. We have experts in pharmacy audit litigation. We can help you request injunctive relief (permission to stop overreaching PBM auditors). Our experts can also assist on post-audit actions challenging unfair audit determinations.

Contact or call us at 866-352-9324 for more info on external audit defense strategies when dealing with PBMs to request a free-non-obligatory consultation.

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