The Pharmacy Benefit Audit Playbook
Audits Every Payer Should Be Considering and How PSG Can Help Pharmacy benefit audits should go beyond checking a compliance box. When approached strategically,…
Clinical and Utilization Management Edit Audits
SOLUTIONS
Clinical and Utilization Management Edit Audits
Utilization management (UM) claim processing edits like the presence of prior authorizations (PA), step therapy, and quantity limits are among the most impactful tools in your pharmacy benefit, but they only work if your PBM is administering them accurately and consistently. With evolving formularies, expanding specialty pipelines, and increasing regulatory scrutiny, even small breakdowns in clinical rule application can lead to inappropriate approvals, unnecessary cost, and member disruption. Clinical and utilization management edit audits verify that your PBM is accurately executing the clinical controls you have in place, from utilization management edit adjudication to the clinical decision-making process behind each prior authorization, providing you the confidence that your clinical programs are performing exactly as intended.
Uncover Hidden Value. Protect Every Dollar
Ensure Contract Compliance
Regular audits verify that your PBM is adhering to agreed-upon terms, from clinical program accuracy to UM edit enforcement, across complex and nuanced contracts.
Recover Dollars Left on the Table
UM edit failures and PA process breakdowns can quietly drive inappropriate approvals and unnecessary cost. PSG audits consistently deliver recoveries and corrective action where issues are identified.
Strengthen Fiduciary Responsibility
Clinical and operational audits are a key component of demonstrating prudent oversight and ensuring that clinical programs are protecting both plan assets and member safety.
Turn Audits Into Strategy
When approached strategically, clinical audits go beyond compliance to evaluate the rigor and effectiveness of your UM programs, enabling more confident clinical and financial decision-making across the pharmacy benefit.
PSG’s Clinical and UM Edit Audits
Clinical Audit | UM Edits Audit
Clinical Audit
A Clinical Audit is a pharmacist-led review of PA designed to assess whether the PBM’s PA process is functioning in accordance with the required PA criteria and as intended by the organization. The execution of the PA criteria and process is confirmed to help ensure that all required elements were collected and used properly, including chart documentation, measurable markers such as lab results, A1C, current weight, and more.
In addition, the stringency of the PA policies and criteria is assessed to ensure optimal drug use. A sample of drug claims across multiple therapeutic categories is selected for review and evaluation. During this review, the audit examines the PA criteria used in each PA review, clinical notes, appropriate use of documentation, and stringency of PA criteria to confirm the PA was approved in accordance with the PA criteria and as intended.
This audit goes beyond checking whether a PA was on file. It evaluates the quality of the clinical decision-making behind each approval, ensuring that clinical rigor is being maintained and that clinical policies are being applied with the depth and precision you expect.
Common Triggers for Conducting This Audit:
- Concerns about PA approval rates that seem unusually high or inconsistent with clinical expectations
- Introduction of high-cost specialty drugs or biosimilars requiring new, updated PA criteria or therapy protocols
- Regulatory changes affecting PA requirements, timelines, or documentation standards
- Patterns of member complaints or provider friction tied to the PA process
- Significant formulary changes that require new clinical criteria or therapy protocols
- Desire to evaluate whether PA stringency is aligned with the organization’s clinical and financial goals
UM Edits Audit
A Utilization Management (UM) Edits Audit includes a review of paid claims to ensure they were adjudicated based on the client’s pharmacy benefit plan for utilization management edits, including PA, age and gender limits, quantity limits, and step therapy. This audit confirms that the PBM is accurately administering and adjudicating clinical plan management protocols in compliance with the pharmacy benefit plan.
Where the Clinical Audit focuses on the quality of PA decision-making, the UM Edits Audit focuses on the operational accuracy of how UM rules are applied at the point of adjudication. It validates that claims requiring a PA were not paid without one, that quantity limits and days’ supply restrictions are being enforced, and that step therapy sequences are being followed as designed.
Even small gaps in UM edit application can quietly compound into significant cost leakage and undermine the clinical intent of your benefit design. These audits help reduce member disruption, support appropriate clinical outcomes, and control costs.
Common Triggers for Conducting This Audit:
- Addition of new UM programs or significant modification of existing clinical edits
- Transition to a new PBM or adjudication platform where UM criteria need to be validated
- Unexpected changes in utilization patterns or per member per month prescription drug expenses
- Known adjudication issues tied to UM edit setup, including PA bypasses or incorrect quantity limits
- Increases in member PA denials and appeals
- Changes in specialty pharmacy vendors
- Concurrent with a plan design or benefit validation audit to ensure comprehensive review of both benefit and clinical rule accuracy
Why choose PSG?
Independence You Can Trust
Our audit findings are free from PBM affiliations or industry bias. When we evaluate your clinical programs, PA processes, and UM edit accuracy, the results are fact based, not influenced by a vendor relationship. That objectivity is what gives our audit conclusions credibility and weight at the negotiating table.
Unmatched Audit Expertise
Our auditors don’t just review data, they understand the clinical programs behind it and how they should perform. Our clinical review audits are performed by pharmacists to assess the appropriateness of medication use in alignment with indication, clinical rule intent, and patient safety standards. This pharmacist-led approach allows us to interpret the numbers with precision, uncover hidden issues, and deliver actionable insights that drive better outcomes for you, which are grounded in deep clinical expertise.
Breadth Across Every Market and Size
No two pharmacy programs are alike, and neither are our audits. Full-scope and a la carte audit options give you the flexibility to target specific areas of concern, whether that’s a focused UM edits review, a deep-dive clinical audit of PA decision-making, or a comprehensive assessment across both operational and clinical dimensions.
Flexible, Tailored Approach
Our audit capabilities span every major market segment (commercial/exchange, Medicare, Medicaid, and beyond). Whether you cover 500 lives or 5 million, we have the experience and methodology to scale accordingly. This breadth means we bring cross-market perspectives to every engagement, identifying patterns and discrepancies informed by what we see across the full landscape of pharmacy benefit programs.