Who’s Initiating Your Audit – Plan Sponsor, PBM or Audit Contractor?

There are numerous entities that may initiate and perform pharmacy audits. While the actual audit process does not vary significantly, there are a few important nuances to understand.

First, the further down the hierarchy (sponsor à PBM à audit contractor), the more opportunities for administrative headaches as each entity has their own processes to deal with. Typically pharmacies must “work their way up”, one level at a time. This does have a benefit in that it may offer more opportunities to appeal an unfavorable finding.

Second, audits initiated by plan sponsors are more common when there is suspicion of fraud, or the audit is labeled as an “investigation”. This is not to say that all audits initiated by sponsors are indications of additional threat.

Here are some examples of common players at each level:

• Plan Sponsor: Aetna, United Healthcare, Centene, State Medicaid
• PBM: Caremark, Elixir, MedImpact
• Audit Contractor: Conduent Payment Integrity Solutions, EXL Health, Integrated Pharmacy Solutions

PAAS Tips:

• PAAS National^® is happy to assist and has experience with pharmacy audits at all levels
• Notify PAAS of an audit as soon as you can in the audit process, the sooner we are involved, the more options we have to assist you