PBM Audits 101: Proactively Protect Your Pharmacy

PBM Audits are painful.

If you’re an independent pharmacy owner, it can be one of the most expensive & stressful hurdles for your business.

You risk losing money and jeopardizing your contract if you are not familiar with PBM manuals and how to apply them to your pharmacy.

In short: with a PBM audit, you’re going to have a bad day.

But, there’s good news. There are ways you can reduce your risk and protect yourself when they come knocking at your door.

Read on to learn four strategies you can execute right away to preserve your business. PLUS we provide you with our comprehensive guide that digs even deeper on how to combat PBM Audits.

1. Document Everything!

The main reason audits are so painful for independent pharmacy owners is the lack of proper documentation. It’s virtually impossible to dig through years of data and remember what you did if it is not documented.

Documentation can save your pharmacy precious time because you’ll be able to access the requested information quickly and efficiently.

Pro Tip: We recommend assigning a point person during the day of the audit that can readily access all the information–whether it’s a signature log in the computer or a hard copy.

Whether it’s big or small, document everything on the prescription, especially if it’s out of the ordinary. This goes for supply changes and early refills.  For example, if you get a prescription for a 30-day supply and the first fill is for 30 and the second fill is for 60, you must document the 60-day supply change or else the auditor will see that change and, without documentation, make a recovery. Whether it is on the hard copy or in the computer system, the documentation must be where the auditor will see it. You will be grateful for having written everything down when you’re staring at an audit.

2. High-Cost Drugs + Your Pharmacy

One of the biggest mistakes owners make is treating high-cost drugs the same as traditional chronic therapy drugs.

Think about it, which is more likely for an audit: a $10 prescription or one that costs a $1,000? Therefore, the documentation for high cost drugs needs to be monitored even more closely.

Pro Tip: We recommend that you assign your best people (and no one else) to self-audit your high-cost drugs meticulously to make sure everything is correct. To take this a step further, you can establish your own audit procedures.

For example, you can assign a team member to pull 10 prescriptions from the previous week and audit them.

Provide a checklist and have your team evaluate whether the 10 prescriptions would pass an audit.

This trains your team to know how to recognize problems and prevent them in the future, making an actual audit go much smoother.

3. Create Standard Operating Procedures (SOPs) for Your Team

What are Standard Operating Procedures (SOPs)?

By definition, they’re a performance tool that helps ensure a standard level of work is completed, even when you’re not at the store.

Without SOPs, you risk having your team members complete tasks differently. Moreover, when a person makes a mistake or does something their own way, you may not know about it until it’s too late. With the proper SOP’s in place each member of your team will be trained to perform key functions the same way every time resulting in fewer errors. Any mistakes that do happen will be caught early.

These discrepancies are what auditors are looking for, so it’s crucial you establish a model that everyone understands to maintain consistency.

Pro Tip: Make sure your team is on board with establishing these operating procedures. This is a good litmus test to see which of your team members are dedicated to your store growth, and which ones will be critical to change.

4. Call the Experts for Help

If you really need to bring in the big guns, don’t be a hero. Save time and energy by asking the experts for help.

We recommend first calling your State Board. Although sometimes they’ll be unable to answer your question, they usually try to do their best to alleviate your fears. Additionally, you can document the conversation to show the PBM you’re taking steps to address any issues your pharmacy might have.

Pro Tip: The next step we recommend is calling Mark and Chris–the founders of Compliance Consulting, LLC and one of our most recommended vendors to our members. (They’ll be at PDS 2019!) Contact them here and mention PDS!

Unlike traditional lawyers, Mark and Chris were both recovery auditors and PBM insiders, so they’re our go-to experts for operational compliance and audits.

When you contact them, they’ll research and share their professional opinion with you on your next steps.

Remember, PBM Audits should not be a cost of doing business.

Be proactive, document everything, pay closer attention to high cost drugs, implement effective SOP’s and call for help when you need it. Following these 4 steps can save you from a nightmare scenario down the line.

[Download the eBook]
PBM Audits 101: What You Need to Know

This is just a taste of what you learn in our latest eBook, PBM Audits 101: What You Need to Know.

Inside, you will learn…

PBM Audits 101: What You Need to Know

  • Types of Audits
  • Audit Triggers
  • What Auditors Look For
  • You Got An Audit, Now What?
  • Interacting With the Auditor

Proactively Protecting Your Business

  • Documentation, Documentation… Documentation!
  • High-Cost Drug Workflows
  • Training Your Team
  • Enlisting Help from the Experts

Buckle up, because this is a comprehensive ride on how to successfully guard against and get through a PBM Audit. Ignore this eBook at your peril.

Koreen Leavitt