We conduct more than 100 audits per year on behalf of our clients, resulting in millions in recoveries and assurance that PBMs are adhering to their contractual and regulatory obligations.  We have conducted audits on virtually all PBMs in the industry, and our experience has helped countless compliance officers and benefit managers rest assured that their benefit plans are in compliance and producing the financial results they expect.

Health Plans

Health plans today are facing more and more pressure to comply with operational and regulatory requirements.  Compliance has become a key component of everyone’s job.  The demands for cost-containment and member protection are greater than ever.  Health plans need a trusted, independent, capable partner to navigate the regulatory environment and provide assurance and expertise.  Our auditors bring years of PBM, compliance, health plan, financial and technical experience to our audit engagements.  We reduce the burden on your internal resources and minimize the stress of regulatory oversight and due diligence.

Our audit capabilities span across all contractual and compliance attestations.  Our team’s vast knowledge of CMS requirements and the regulatory environment for health plans can assist you in managing oversight of your plans.  We have served as the independent validation auditor for numerous CMS program audits, performed mock audits, and trained clients on how to conduct mock audits internally.  Our team is also a leader in CMS data validation and pre-assessment audits, having conducted hundreds of data validation audits since 2010.

We custom design audit and compliance solutions based on your greatest risk areas, giving you the confidence and transparency that you seek.  Our audit capabilities include:

Contractual Audits (Commercial, Medicare & Medicaid)

  • Plan design or benefit audits
  • Rebate audits
  • Pricing audits
  • Eligibility audits
  • PBM program implementation or post-implementation audits
  • Fraud, waste, and abuse audits
  • Clinical program audits
  • Performance guarantee audits
  • Mail order audits

CMS Compliance Audits

  • Mock CMS program audits
  • CMS validation audits (independent revalidation audits)
  • CMS data validation reviews
  • CMS data validation pre-assessment consulting
  • Compliance program effectiveness audits
  • Prescription Drug Event audits
  • Coordination of benefits audits

Employers, Unions & Labor Trusts
Your benefit plans should be a benefit to your employees, not a daily concern. Whether you’ve received an unexpected PBM invoice, or you just don’t know what you don’t know, we can help you see inside the PBM black box.  We help our clients uncover issues that may have fallen through the cracks.  Our auditors have conducted hundreds of audits for employers just like you, and we can design customized audit solutions that give you assurance that you’re not overpaying for your benefits, and that your employees are getting the most from their pharmacy benefit.

Our audit capabilities include:

  • Plan design or benefit audits
  • Pricing audits
  • Rebate audits
  • PBM program implementation or post-implementation audits
  • Eligibility audits
  • Fraud, waste, and abuse audits
  • Employer group waiver plan (EGWP or EUGP) audits
  • Retiree Drug Subsidy audits
  • Financial statement of work audits
  • Performance guarantee audits

Maximize Savings, Mitigate Risks and Optimize Effectiveness

We take a data-driven approach and work with you to develop and recommend a pharmacy program that fits your individual plan needs – helping you maximize savings, mitigate financial and regulatory risk, and optimize effectiveness. Contact us to learn more.