Pharmacy benefit manager (PBM) audits remain one of the most significant compliance challenges facing independent and community pharmacies. While PBMs characterize audits as tools to identify fraud, waste, and abuse and ensure pharmacies comply with their network agreements, audits can have serious operational and financial consequences. Depending on the nature of the review, pharmacies may face monetary recoupments, audit fees, regulatory scrutiny, and even network termination, making it critical for pharmacy owners and operators to understand how audits work and what factors may trigger them.
In a video interview with Drug Topics, Harini Bupathi discussed the purpose and realities of PBM audits and why pharmacies should take them seriously. She noted that while audits are intended to monitor compliance with provider agreements and manuals, they are often used for broader purposes that can significantly impact pharmacies’ businesses.
“It’s really important that all pharmacies really understand what a PBM audit is. It’s essentially a review on network pharmacies to ensure that they’re meeting their terms and conditions under the provider agreements and their provider manuals.”
