How do you prevent a PBM auditor from clawing back monies?

Pharmacies deal with the threat of PBMs clawing back money daily.  Fortunately, many audits resulting in the clawback of monies can be prevented by proactive activities, training, and overall employee understanding.  These activities start before the prescription is filled and dispensed and continue after the patient walks out the door. These activities mean more work, but it is work that you and your employees need to be considering as you are filling potentially high audit risk medication.  I do not want to claim this is a simple process or that the PBMs will not change the game with another scheme not to pay Pharmacies.

We are talking about the clawbacks caused by “innocent” mistakes in the Pharmacy that could have easily been prevented, not the gross overreaching by the PBMs and their changing goalposts. Still, these audits result in outcomes that affect an owner’s ability to pay employees, grow the business, payout bonuses, provide raises, and many other things.  So, it does not just affect the owner; it affects everyone in the Pharmacy.

Where should you start?

You want to start looking at the lowest hanging fruit and those claims that are commonly audited, including:

  • Expensive Prescriptions
  • Dispense as Written codes 1 and 2
  • Eye/ear drops
    • Solutions – approximately 20 drops/ml unless stated otherwise on the package
    • Suspensions – approximately 15 drops/ml unless stated otherwise on the package
  • Insulins
  • Creams and ointments
    • Do not dispense large quantities unless justified by directions
  • Inhalers
  • Verifying day supplies
  • Products in unbreakable packaging
  • Everything else

As you review these claims, you want to make sure they are correctly entered into the Pharmacy Software and have all the necessary information.  Pharmacy Owners need to make sure their employees know the “higher risk” of these claims.  Employees need to be taking the appropriate actions before data entry, during the filling, and while the Pharmacist is checking and dispensing.

Targeted Follow-up Review

These claims should be reviewed after filling and dispensing to ensure they were entered and filled correctly.  Hopefully, all is well and nothing needs to be done.  If there is a problem, the targeted review will identify the issue, correct the issue, and hopefully prevent the issue from occurring in the future.  These targeted reviews should occur as frequently as possible (based on your Pharmacy Operation – maybe weekly) to ensure any issues are caught before refills occur and a clawback turns into a multi-dispensing nightmare.

Dispensing Creams, Ointments, Ophthalmic, Otic and similar items

When you review directions, pay close attention to “PRN” and “as directed” – instructions like these can be troublesome and potentially lead to larger quantities dispensed than required.  The Pharmacist needs to justify issuing large package sizes by clearly documenting their conversation with the patient and the prescriber to justify dispensing packages that appear excessive for the contractual day supply limitation.

Document your conversations with the Patient and Prescriber’s office

Documentation is king.  When the Pharmacist communicates with a prescriber’s office (or even the patient), there should be clear documentation that includes:

  • Date and Time of the conversation(s)
  • To whom did you speak
  • The outcome of the conversation
  • Pharmacist’s initials

Document your conversations with PBM Helpdesk

Ensure you document your calls with the PBM, especially when PA, DUR, and override codes are being used. You should not apply any PA, DUR, or override codes without an apparent and documented reason for using a particular override.

Other Compliance Issues that may come up during a PBM Audit

We went over the claims and billing information above.  However, these are not the only items that PBMs may review when conducting audits or credentialing.  You need to be aware of “Compliance and Policy” issues the PBMs and their auditors are looking for also, including:

  • Will Call Bin Cleanup
  • Proof of Delivery / Pickup
  • Copay Collection
  • Usual and Customary Submission Policy
  • Hardship Policy
  • Invoice Review (looking to make sure you had the product to dispense)
  • Medicare Part D:
    • Training
    • Conflict of Interest Attestations
    • Code of Conduct and Ethics Attestation
    • Compliance Program
  • USP 795 (as applicable)
  • USP 797 (as applicable)
  • USP 800 (as applicable)
  • Claims Reconciliation
  • Any items you attested to when you signed the Payer or PSAO Agreement


Ultimately, the issue of PBM excessive clawbacks (including DIRs) place immense pressure on Pharmacy.  The clawback of monies is hurting Pharmacy owners and patients alike.  Pharmacies need to take steps to combat these events before they even happen, a preemptive strike to fight clawbacks before they occur.

PRS’s COMPLIANCETrack is a family of programs designed to help you comply with many compliance areas reviewed and required by PBM and other entities.  These include:

  • Fraud, Waste, and Abuse
  • Vaccine best practices
  • OIG and SAM Exclusion Checks
  • CLIA Waived Best Practices (Point of Care Testing)
  • Medicare Part B Compliance
  • DMEPOS Accreditation
  • Cultural Competency
  • USP 795
  • USP 800
  • And more

These Programs provide Policies, Procedures, and Forms that follow the related Regulations.  The programs also provide training based on the policies and procedures and regulations, so there are no worries whether your employees are receiving training or just education.

For more information about PRS Pharmacy Services’ Pharmacy Compliance Offerings, click on the following link, COMPLIANCETrack, or call PRS at 1-800-338-3688. Join the thousands of independent pharmacies that currently enjoy the benefits of PRS’s Compliance Programs.