A practical guide to PBM audits: Reducing risk in medically integrated dispensing
By ION
Pharmacy Benefit Manager (PBM) audits are detailed reviews of pharmacy records designed to confirm compliance with contracts, billing procedures, and regulatory guidelines. While they serve an important role in preventing fraud, waste, and abuse, they also carry real operational and financial implications. For multispecialty practices with medically integrated dispensing (MID) programs, PBM audits are an expected part of operations – and disciplined workflows and documentation habits are essential to avoiding negative outcomes.
PBM audits typically examine prescription records, billing practices, inventory management, and copay collections. They often focus on elements tied to claim accuracy and clinical integrity, such as dispense as written (DAW) codes, directions for use (SIG), National Drug Code (NDC) accuracy, quantity authorized vs. dispensed, and refill timing. Audit findings can lead to recoupments, network compliance issues, and increased payer security.
Pharmacists and certified pharmacy technicians working in MID settings play a critical role in ensuring claims accuracy, patient safety, and compliance. The best way to both significantly reduce audit risk and pass a PBM audit if it arises is to embed best practices into daily workflows to ensure consistent compliance procedures for processing prescriptions. Cencora recommends several best practices to reduce audit risk, including:
- Align DAW codes with prescriber intent and confirm accuracy of the origin code.
- Use clear directions and avoid SIG abbreviations. Do not default to 30/60/90-day supply without clinical justification.
- Never alter written quantities without prescriber clarification. Ensure day supply matches the actual quantity dispensed and the documented instructions.
- Dispense the exact NDC billed and verify every digit matches what was submitted to the PBM.
- Document all required changes directly on the hardcopy or electronic prescription to maintain integrity and patient safety.
- Reverse claims for prescriptions not picked up within 10 days and never modify the original written date of a prescription.
By standardizing documentation and prioritizing meticulous claim accuracy, pharmacy teams can reduce audit risk, support compliant operations, and strengthen patient safety.
The IntrinsiQ Specialty Solutions team recently shared a deeper overview of PBM audit best practices and walked through Cencora’s audit support services in a webinar that you can view below. If you would like to learn more about our pharmacy services and solutions – including PBM audit support – contact our team at info@intrinsiq.com.
