PBM Benefit Audits: Understanding Health Plan Rights and Best Practices

Presenters: Derek Frye, Practice Leader - Audit & Compliance; Lynn Stauffer, Audit Lead - Audit & Compliance

This event has ended. The slides are published here, and the recorded session is accessible here.

The increasing array and complexity of pharmacy benefit designs, changing regulations, and rapid industry consolidation have significantly increased the chances your PBM will make errors on a large scale. These can negatively impact your health plan’s bottom line, increase your compliance risks, and undermine service levels, leading to reduced member satisfaction.


In fact, more than 90% of PBM benefit plan audits performed by our firm in the last six months found significant underpayments and/or overpayments involving health plans or members -- in some cases totaling millions of dollars. In this webinar, The Burchfield Group’s audit and compliance experts will discuss why it’s more important than ever that health plans conduct PBM benefit audits regularly – and what’s involved. You will learn:  

  • Common benefit plan design offerings and typical formulary drug coverage options.

  • The four major components that should be reviewed as part of a benefit audit.

  • The top 8 error types uncovered as part of benefit audits, along with sample findings from actual audits.

  • Health plan best practices and typical timelines for performing benefit audits.

  • What audit rights health plans must specify in their PBM contracts in order to conduct an effective benefit audit.

  • Why health plans should incorporate a benefit audit as part of their broader PBM audit strategy.