Is Your Pharmacy Ready for a PBM Audit?
Invoice reconciliation audits are the starting point of most PBM investigations — these PBM audits are often unfair, aggressive, and driven by data discrepancies. These discrepancies even can lead to rejection of insurance claims, and also network cancellation, if not managed properly.
Keep yourself ahead of the PBM Audit with compliance-focused strategies and professional reconciliation services.
Understand the PBM Audit Threat
Pharmacies rely heavily on insurance reimbursements processed through PBMs (Pharmacy Benefit Managers).PBMs such as OptumRX, Express Scripts, CVS Caremark, and Humana—hold the authority to scrutinize your billing records, approve or reject claims, and conduct invoice audits, which can lead to Network Termination, if not handled properly.
Billing for high-volume or specialty drugs can feel like walking a tightrope. PBMs watch these drugs closely because they’re expensive, and any unusual billing patterns—whether they are due to
quantity, frequency, or specific coding issues.
Minor billing errors flagged as major compliance issues
Lack of or Gaps in documentation or not being in compliance with the PBM contract terms
Unfortunately, PBMs are known to act without warning or proportionality—often disconnecting pharmacies from insurance networks over technicalities. This can instantly halt your ability to serve patients and devastate revenue.
Unfortunately, PBMs are known to act without warning or proportionally—often disconnecting pharmacies from insurance networks over technicalities. This can instantly halt your ability to serve patients and destroy revenue.
Why Independent Pharmacies Trust Axotech
PBM Audit Compliance
We perform readiness checks for new and existing pharmacies, so you can confidently apply to PBMs or submit licensing documentation knowing you're audit-ready.
PBM Audit Defense
Already under audit? Our team quickly intervenes, compiles necessary data, and supports you through response submissions to help prevent insurance network disconnection.
Documentation Support
From prescription records to purchase logs, we ensure your internal data aligns with PBM expectations and industry regulations.
Our Specialized Services
Invoice Reconciliation Audit
Before a PBM does—find every inconsistency in purchase vs. billing data.
This is where every audit starts and where mistakes are most costly.
Before a PBM does—find every inconsistency in purchase vs. billing data. This is where every audit starts and where mistakes are most costly.
Monthly Compliance Monitoring
Get monthly snapshots of your compliance health. Our reports help you fix issues
before PBMs use them against you in an audit.
Get monthly snapshots of your compliance health. Our reports help you fix issues before PBMs use them against you in an audit.
Emergency Audit Assistance
We work fast when you need it most. Our audit team helps prepare documents,
defend your position, and communicate directly with the PBM.
We work fast when you need it most. Our audit team helps prepare documents, defend your position, and communicate directly with the PBM.
Learn More from Our Experts
Explore articles that provide insights and tips for navigating PBM audits, invoice reconciliation, and more.
We helped a pharmacy avoid PBM removal through smart audit and legal strategies.
Lina Khan’s pharmacy visit signals increased attention to PBM audit practices and fairness.
Trends show tighter checks. Prepare early with the right audit strategy and documentation.
Non-compliance, billing errors, and missing records are top reasons for PBM investigations.
Facing a PBM Audit or Network Termination?
Don’t risk your business. Contact us now for a proactive reconciliation audit, expert guidance, and PBM-specific compliance support.